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Professor of Medicine in the University of Berlin. 

Volume I.— Acute Infective Diseases. 






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In laying down, now twenty-five years ago, a plan 
to be followed in the preparation of a Handbook of 
Geographical and Historical Pathology, I was fully 
aware of the difficulties that attended both the execu- 
tion of the work and the introduction of it to the 
professional public ; and, in the preface which I issued 
with the first part of the book, I spoke of these diffi- 
culties plainly and without reserve. The task that I 
had imposed on myself was not merely to collect 
and reduce to order an almost unmanageable heap 
of materials — for the most part a rudis indlges- 
taque moles — and to test critically their authenticity 
and fitness ; but it more particularly involved the 
founding according to a design, and the building up 
according to a system, of a discipline which had been 
the subject of but little labour before, and had still to 
make good its right to a place among the Medical 

The misgivings which these difficulties gave rise to 
in me as I approached the execution of my task 
proved to be only too well justified, in one direction 
at least, as the work proceeded. Notwithstanding the 
quantity of material that I had collected, there were 
considerable gaps which it did not cover; and, more- 


over, when T came to test its suitability for tlic object 
in view, it contracted into smaller and smaller bulk, so 
that the book, when it was finished, remained much 
behind even the modest expectations that I had 
set out with. I have been more fortunate in over- 
coming the difliculty that faced me in the other direc- 
tion — the diflicultv of o-aining^ the ear of the learned 
world of medicine to the subject of which I treated. 
Their interest declared itself, not merely in the favor- 
able opinion that was soon expressed of mj work on 
almost every hand, but also in the increased attention 
that has been given since then to the study of 
Geographical and Historical Pathology. I may there- 
fore permit myself to think that this work of mine, 
however defective it has always seemed to myself, has 
provisionally satisfied a want that was felt, and has 
given an impulse to the further cultivation of this 
field of medical knowledge; and, in writing now, I 
may say without boasting that the progress made 
within the last thirty years by this discipline, with its 
decided influence on the course of etiological inquiry 
and its infusion into it of a more scientific character, 
has been connected in no small degree with the 
publication of my book. 

The start which the geographical and historical 
study of disease has taken in recent times has left the 
book more and more out of date; and the desire to go 
over the ground again, which I began to entertain 
shortly after the work appeared, has graduall}^ come to 
be a duty. The distinguished services in the field of 
Medical Geography rendered by French, English, and 
American physicians during the last thirty years 
through the publication of monographs, official reports, 
or journals specially devoted to the subject — 1 may 


mention in particular the recent series of Health Reports 
of the War Offices of England and the United States, 
and the ' Archives de medecine navale ' — have brought 
us much valuable information as to the Climate and 
Medical Anthropology of many large regions of the 
globe, which were formerly unknown in these respects, 
or known very imperfectly. "We have also the copious 
epidemiographical literature of recent years, which has 
left hardly a single subject relating to Epidemics 
untouched, and whose treatment of them has been in 
most cases extremely thorough ; this division also, like 
that of Medical Geography, has its special organs, 
among which I shall mention the Reports issued by 
the English Health Department, the Official Sanitary 
Reports for Sweden, and the ' Transactions of the 
Epidemiological Society of London.' All such labours 
have not onlv added on the o-rand scale to our knowledg-e 
of the distribution of diseases in time and in place, and 
of the causal connexion between them and the human 
environment ; but, moreover, these researches have 
been invested with a scientific value such as pertained 
to only a small part of the earlier writings in the field 
of Medical Geography; for the standpoint of observers 
at the present day is completely changed from what it 
used to be, representing as it does the latest form of 
pathological opinion. Nowadays we can estimate the 
health-conditions of many of the most remote parts of 
the world, in regard to morbid anatomy and etiology, 
with as much exactness as we were privileged to do 
not so very long ago, for none but the most civilised 
States of Europe and North America. It is unneces- 
sary for me to say how much we are likely to profit 
by this even in our knowledge of those matters of 
professional j)ractice that concern us nearest home. 

viii AUTnoR's preface. 

Thus it is that Medical Geography and the History 
of Diseases bears to-day a character quite different 
from that of the science twenty or thirty years ago. 
It has filled out in proportions, and acquired finish to 
an extraordinary degree ; and it seemed to me that 
some attempt to treat of Geographical and Historical 
Pathology anew was not merely justified, but even 
called for. 

It will be apparent that my task has not consisted 
merely in amending and amplifying my work of 
twenty years ago, or in bringing out an edition of it 
" improved and enlarged." It has involved rather an 
entirely new treatment of the subject; and, although 
I have ventured to retain the general ground-plan of 
the original work, I have allowed a good deal of 
enlargement on the side of Comparative Pathology, 
and still more on the side of Etiology ; while, on the 
other hand, I have introduced some restriction in the 
choice of subjects, or some compression in the 
treatment of them. Some diseases have so little of 
geographical and historical interest that they may 
be appropriately left unnoticed altogether, or disposed 
of in a passing reference. There are other diseases 
which have hitherto attracted so little of the attention 
of observers at various parts of the world that the 
writings upon them are of the most meagre and defec- 
tive kind; it was impossible to arrive at a tolerably 
sound opinion on their historical and geographical 
position, or on the causal relation between them and the 
active factors in the etiology, and it seemed advisable, 
therefore, merely to mention them in order to indicate 
the gaps in our knowledge, and perhaps to call forth 
more thorough inquiries and more comprehensive 


With these curtailments I shall not find it necessary 
to go materially beyond the size of the first edition of 
this Handbook, notwithstanding the expanded treat- 
ment of the more important groups of diseases — the 
Acute and Chronic Infections, the Constitutional 
Anomalies of general prevalence, the Endemic Morbid 
Processes (which are so full of scientific interest in 
many ways), and such Local Aff"ections as have the 
character of public or national maladies. 

I now hand over my work to the learned medical 
world with the wish that it may meet with as favor- 
able a reception as the first edition of the Handbook 
has enjoyed. Although I am far from ignoring the 
many lacunas and faults that are still present in the 
work, I can assure the reader that I have laboured 
according to my strength to make it as complete as 
possible. I am not without hope that I have made it 
more available for those circles of practitioners who 
are accustomed to judge of the worth of a scientific 
piece of work according to its immediate usefulness — 
from the so-called " practical " point of view — and 
who have hitherto regarded Geographical and His- 
torical Pathology as a matter of abstract scientific study 
l}dng remote from their needs ; available also for those 
persons whose lofty confidence in their own experience 
leads them to look upon historical inquiry in Pathology 
as so much unprofitable 'dead- weight or as a superfluous 
luxury, and who thereby succeed in bringing the field 
of their mental vision within the narrowest possible 

I have, in conclusion, a pleasing duty to perform in 
offering my most obhged thanks to the Directors of 
Health Departments, of Medical Departments of the 
Military Services, and of Statistical Departments, as 


Tvcll ns to the large inimber of Home and Foreign 
]\Ieclical Societies, for tlieir liberality in keeping me 
supplied ^vith their published reports, and thereby- 
placing me in possession of materials invaluable for 
the composition of this treatise. 

August Hirsch. 

Beelin ; Juyie, 1881. 


The English-speaking race are most directly interested in the sub- 
ject of this book, and their observations in various parts of the world 
have supplied a large part of the materials for it. Our indebtedness 
to Professor Hirsch for his self-imposed labours is all the greater 
on that account. Having now translated the first volume, and 
transcribed several thousands of references, I can form some idea of 
the author's task. In a letter, which I venture to quote, he says of 
the new edition : " Es steckt in dem Buche eiu grosses Stilck 
meines Lebens und eine unsagbar miihselige Arbeit, mehr Arbeit 
als mir aus der ersten Ausgabe erwachsen ist, da das Material 
innerhalb der letzten zwanzig Jahre sich verzehnfacht hat." The 
new edition will be in three volumes, of which two have been pub- 
lished. The volume that is now translated came out in the summer 
of 1 88 1 ; the second, containing the Chronic Infective, Parasitic, and 
Constitutional Diseases, in the summer of this year ; and I learn 
from the author that the concluding volume, treating of Local 
Diseases (or Diseases of Orgjins), may be looked for in the spring 
of 1884. 

The Index is an addition of my own. ]S"ames of places occur so 
often in the text that it would have made the Index somewhat 
unmanageable to have inserted every mention of them ; I have 
accordingly given a preference to those where an authority is 
quoted, and I venture to hope that the Geographical part of the 
Index will thus serve as a clue to the Bibliography, more espe- 
cially for those chapters which have no alphabetical list of authors 


LOXDON ; November, 1883. 

appended. Professor Hirsch has taken the trouble to read the , 

proof sheets, so as to ensure that the sense of the original shall not ; 

have been seriously missed in any passage. j 



INTRODUCTION . . . . .1—6 

INDEX ..... 689—710 


INFLUENZA (§§ i — 11). 

Always occurs as an Epidemic or Pandemic — Mode of Progres- 
sion — Geogi'apliical Distribution — Relation to Seasons and 
Weatlier — Special Liability of Natives and Exemption of 
Strangers — Influence of the Weatlier in the Causation — A 
Specific Infection — Alleged Contagiousness — Uniformity of 
Type — Coincident Outbreaks of Influence among Horses — 
Literature of Influenza .... 7 — 54 


DENGUE (§§ 12—18). 

A Comparatively New Disease .- its Symptoms — Geographical Dis- 
tribution—Characteristics of Dengue as an Epidemic — A 
Disease of the Tropics and of Hot Seasons — Influence of 
Locality — Slight Influence of Race, etc. — Specific Character : 
Question of its Communicability — Literature of Dengue- 
Sickness . . . . . , 55 — 81 



A. The English Sweating Sickness. Historical Outbreaks : 

the Symptoms — Associated Circumstances. 

B. Miliary Fever. (Suettes des Picards. Suette Mili- 

AIRE.) — Confused Identity in Old Writings — History and 
Chronology of the Epidemics in France — Italian Epidemics — 


Othor Epidemics, mostly German — Limited Area — A Disease 
of Short Duration — Close Dependence on Season and Wea- 
ther — Influence of Locality — A Country Disease, but not par- 
ticularly of the Peasanti'y — A Specific Infection : Relations 
to other Diseases — Question of its Comraunicability — 
Identity of Miliary Fever with the English Sweating Sick- 
ness — Coincidence with Cholera Epidemics — " Cholera Su- 
doral " — Literature of Miliary Fever . . .82- 122 


SMALLPOX (§§ .u-4^). 

Its Antiquity and Original Habitat — Geographical Distribution 
— Influence of Vaccination on the Prevalence of Smallpox — 
Periodicity of Epidemics — Influence of Season — The Specific 
Poison of Smallpox — Individual Susceptibility to the Poison 
— Difi'usion of the Morbid Poison — Relation to Chicken-pox 


MEASLES (§§ 43-49)- 

Old Views of " Morbilli :" the History Defective— Present Geo- "^ 

graphical Distribution — Epidemic Recurrence— Influence of \ 
Season — Mildness or Severity of Type— Severity of Type due 

to Neglect of the Sick — The Specific Poison of Measles 154 — 170 i 


SCARLET FEVER (§§ 50—58). 

Historical Notices Defective — Present Geagraphical Distribution | 

— Peculiarities of Scarlatinal Epidemics as compared with \ 

those of Smallpox and Measles— Influence of Seasons and j 

Weather— Unaffected by the Nature of the Soil— Mildness ! 
or Severity of the Type of Disease— The Virus of Scarlatina 
—Original Habitat Uncertain— Diffusion of the Morbid 

Poison . . . . . 171— 196 \ 



Geographical Distribution— Epidemics and Pandemics— Old \ 

Seats and New— New Types— Regions of Intermittents, j 

Remittents, and Malarial Cachexia— Regions and Circum- > 


stances of Quotidian, Tertian, or Quartan Fever — No Race 

or Nationality immune — Acclimatisation — Influence of Cli- 
mate and Season — Influence of Heat — Influence of Moisture 
— Rain or Dew — Influence of Winds — Altitude and Con- 
figuration of the Ground — Geological and Physical Cha- 
racters of the Malarious Soil — Saturation of the Soil — 
Organic matters in the Soil — Changes in the Soil — Cultiva- 
tion, Neglect of Cultivation, Excavations, Volcanic Disturb- 
ances—Exceptions to the Rule that Marshy Soils are 
Malarious— Malaria in Dry Places, Anomalous Exacerba- 
tions, Epidemics and Pandemics— Ship Malaria — Necessary 
to assume a Specific Poisonous Substance — Search for Germs 
— One Malarial Poison or Several — Alleged Diff'usion by the 
Wind — Absence of Contagious Power — Literature of Malarial 
Diseases ..... 197 — 315 


YELLOW FEVER (§§ 80—98). 

Peculiar Geographical Distribution — Chronology of the Epi- 
demics — Characteristics of an Epidemic— Influence of Race, 
Nationality, and Acclimatisation — A Disease of the Tropics 
and the Hot Season — Relations to Heat and Cold — Influence 
of Moisture and Winds — Seldom leaves the Sea-Coast or the 
Banks of Navigable Rivers — Limited Altitudinal Range — 
An Urban Disease — Haunts the Low and Filthy Quarters of 
Seaports — Epidemics on Board Ship — Geological Characters 
of the Soil of no Account — Malarious Conditions of Soil are 
Irrelevant for Yellow Fever — Nature and Origin of the 
Morbid Poison — The Question of Communicability — Goes 

no farther than Maritime Commerce goes — Alleged Diff'usion 
by the Wind — Diff'used by Personal Intercourse or Goods 
Traffic — Endemic at Three Points Only — Literature of Yellow 
Fever . . . . . 316—393 


ASIATIC CHOLERA (§§ 99—122). 

First Pandemic, 1817-23 — Second Pandemic, 1826-37 — Third 
Pandemic, 1846-63 — Fourth Pandemic, 1865-75 — Countries 
that have Escaped Cholera — ^Its Native Habitat — Cholera 
in India and Elsewhere previous to 181 7 — Conditions Favor- 
able to its Origin and Diff'usion — Influence of Altitude — 



Follows tlie Rivers— Favouring Characters of the Soil— In- 
Uuencc of Seasons and Weather— InHuence of Heat— Influ- 
ence of Moisture— Pettenkofer's Law of the Sub-soil Water 
—Barometric Pressure— Wind— Mortality unaffected by 
Climate — Predisposition of Individuals, Races, and Nation- 
alities—Nature of the Morbid Poison, Mode of Reproduction, 
and Manner of Diffusion— Experiments to Communicate 
Cholera to Animals ; Criticism of the Same— The Question 
of Contagiousness— How far Dependent on the Soil— Epi- 
demics on Board Ship— Diffusion by Human Intercourse. 
Religious Festivals of the Hindoos— Drinking- Water as a 
Vehicle of the Poison .... 394—493 


PLAGUE (§§ 123— 131)- 

Ancient, Media;val, and Modem Epidemics ; the Black Death 
—Recent Outbreaks in Asia Minor, &c.— Relation to Cli- 
mate—Relation to Soil and Altitude— Intimately Connected 
with Want and Filth— Susceptibility of Different Races 
to the Morbid Poison — Native HalDitats- Importation — 
New Foci — Disappearance from Egypt — The Means of its 
Diffusion — Nosological Characters — Pulmonary Hasmor- 
rhage— Identity of the Black Death with the Pali Plague 494—544 


TYPHUS (§§ 132—142). 

Historical : the Great Typhus Periods from 1708 to 18 15 — Recent 
Epidemics, Irish and Other — Present Geographical Distribu- 
tion — Mostly a Disease of the Temperate and Cold Zones — 
Connexion with Cold Weather — Independent of Telluric Con- 
ditions — Epidemic Typhus Coincident with a Time of Want 
— Associated \vith Filth, Overcrowding, and Privations — 
Origin of Tyj)hus : the Virus — Native Habitats — Contagious- 
ness of Typhus — Race and Nationality without Influence 545 — 592 



The Scotch and Irish Epidemics ; Present Geographical Distri- 
bution — Coincidence with Typhus — Not Dependent on 


Climate — Little Influenced by Weather — No Relation to the 
Soil — Relation to Overcrowding and Privations — Question 
of its Spontaneous Origin or of its Parasitic Nature — A 
Communicable Disease — No Preference for Race or Nation- 
ality ..... 593— <5i6 


TYPHOID (§§ 152—168). 

Confused Identity in Earlier Writings — Present Geographical 
Distribution — An Ubiquitous Disease ; Comparative Immu- 
nity of the Tropics — Relation to the Seasons — Relation to the 
Temperature — Relation to the Rainfall — Associated with 
Certain Conditions of Locality — Occurs in Elevated and Low 
Situations equally — Relation to the Physical Characters of 
the Soil — Associated with Fluctuations in the Sub-soil Water 
— Relation to Neglected Hygiene— ^Special Relation to Faulty 
Sewerage — A Communicable Disease ; Question of Autoch- 
thonous Origin — Mode of Diffusion of the Morbid Poison — 
Acclimatisation ; no Racial Exemptions — Drinking- Water 
and Milk as Vehicles of the Poison — Antagonism between 
Malaria and Typhoid . . . . 617—688 





The life of the organic world is the expression of a pro- 
cess called forth and sustained, in organisms that are 
capable of life, by the sum of all the influences which act 
upon them from without. The form and fashion of this 
process, accordingly, are determined by the kind of 
individuality and by the character of the environment. 
Each of those two factors shows many differences in time and 
in space. As regards the human species, the differences 
are expressed, for the first factor, in the distinctive qualities 
of generations separated by years, and of races and 
nationalities scattered over the globe ; for the second factor, 
they are expressed in peculiarities of the climate and the soil, 
and of the animal and vegetable kingdoms in so far as these 
are brought into direct relation with man, and further, in the 
vicissitudes of politics, of social affairs, of the food-supply, 
and of mental training. 

In these considerations lie the germs of a science, which, 
in an ideally complete form, would furnish a medical history 
■of manhind, but which, treated more narrowly and so as to 
embrace only the pathological side of human life, will give : 
firstly, a picture of the occurrence, the distribution, and 
the types of the diseases of mankind, in distinct epochs 
of time, and at various points of the earth^s surface ; and, 
secondly, will render an account of the relations of those 



diseases to the external conditions surrounding the individual 
and determining his manner of life. And this science I 
have named, from the dominating point of view, the science 
of gcogy-aphical and Jiistorical pathology. 

The first attempts to attain, bj way of anthropological 
observations at various parts of the globe, some knowledge of 
how the particular fashion of human life is dependent upon the 
peculiarities of the individual and of his surroundings, reach 
back to the time when medicinewas impregnated with the spirit 
of Hippocrates, whose treatise, 'irepi acpan', vBarwv, roVwr',' laid 
down the lines of scientific investigation on this subject. His 
successors little understood the need of such labours ; only in 
a few of the best Greek and Roman medical authors, such as 
Celsus, Asclepiades, and Aretaeus, do we find here and there- 
indications that they gave some attention to the various 
effects of climate and diet upon the human organism 
in health and disease. Such questions were unfamiliar to 
the physicians of the middle ages ; and it was only in the 
sixteenth century, when distant countries and new worlds 
were opened up and explored, when the impulse to observe 
was awakened, and the study of nature came to displace 
dogmatic speculation, that naturalists and physicians again 
endeavoured to find matter for scientific investigation in the 
changing aspects of organic life at various parts of the globe. 
Along with the animal and vegetable kingdoms, man was 
included in the scope of these investigations. At first it 
was things remote and unaccustomed that attracted the 
attention of observers, but they soon turned to objects near 
at hand. Thus, botany and zoology, which had made, since 
Aristotle's treatment of them, no progress worthy to be 
mentioned, acquired a scientific character ; and at the same 
time research came back, not always consciously, to those 
inquiries of Hippocrates on the influemS^ of climate, soil, and 
manner of life upon the habit of the human body. Not only 
physicians and naturalists, but also many educated travellers, 
contributed to this record of observations in medical 
geography and topography, — a record which had reached 
such proportions towards the end of the eighteenth century, 
that a systematic recapitulation of it became necessary. 
The first attempts at a scientific handling of the subject were 


Finke's ' Versucli einer allgemeinen medicinischen Geo- 
graphie,^^ and Schnurrer^s ' Geographische Nosologic/ Not 
to mention several more special or less important treatises 
on the subject, these are succeeded by such works of modern 
date as Miihry^s ' Die geographischen Verhiiltnisse der Krank- 
heiten,'" Bondings ' Traite de geographic et statistique modi- 
cales/^ and the great work lately published by Lombard, 
' Traite de climatologie medicale/'* 

As the titles of those works indicate, the several authors 
have taken up different standpoints in their treatment of the 
subject, the standpoint either of the geography or of the 
pathology ; they have given either a geographically arranged 
account of the types and of the relations to climate, soil, 
culture, race, &c., of the normal and pathological processes 
of life at various parts of the globe, that is to say, a medical 
geography properly so-called ; or they have on principle 
confined themselves to the pathological standpoint, and have 
directed their investigations to the mode of distribution of 
diseases over the earth, and to their dependence upon changing 
external influences — for the most part with a good deal of 
one-sidedness and with preponderating if not exclusive regard 
to climate — that is to say, they have taken up the ground of 
geographical pathology. 

The same period which produced the earliest of those 
medico-geographical works, saw also the first attempt at a 
historical handling of pathology, an endeavour to exhibit 
the comportment and types of diseases within the several 
epochs of time through which the human race has passed. 
Investigations in this field received a decided impulse from 
the outbreak of widespread and severe pestilences, about 
which men sought in vain for enlightenment in the received 
authorities of past times— --in Hippocrates, Galen, and Avi- 
cenna. In this way there was awakened an interest in the 
study of epidemiology, which the numerous epidemiological 
works of the sixteenth and seventeenth centuries bear 

I Leonhard L. Finke, ' Versuch einer allgemeinei mediciniscli-praktischen 
Geograpliie,' 3 vols., 8vo, Leipzig, 1792 — 5. 
- Two vols., 8vo, Leipzig, 1856. 
' Two vols., 8vo, Paris, 1857. 
^ Two vols., Svo, Paris, 1S77. 


witness to ; and naturally associated therewith were inquiries 
designed to discover in the writings of antiquity or of the 
middle ages, indications of the occurrence of this or that 
form of pestilence, and to find out how much the physicians 
of those times knew of the diseases in question. This 
inquiry was for the most part conducted from a very simple 
point of view ; it was either a kind of search for antiquities 
or curios, or it took an especially philological direction. It 
was not given up until towards the end of the eighteenth 
century, when the enormous quantity of epidemiological 
material collected from previous centuries gave occasion to 
a sifting and scientific elaboration, and urged forward the 
pathological and etiological, rather than the historical, side 
of the question, and thus gave a different turn to research. 

The historical investigation, like the geographical, had from 
the outset a dual character, inasmuch as it adopted either 
the chronological standpoint or the pathological ; it turned, 
moreover, towards that side of pathology exclusively, which 
afforded or seemed to afford especial interest for historical 
treatment, towards the group of diseases that occurred as 
epidemics or endemics — the so-called people's plagues 
{VoUissencJie). Among the best known writings belonging 
to the first, or chronological class, are Noah "Webster's 
' Brief History of Epidemic and Pestilential Diseases,'^ and 
Schnurrer's ' Chronik der Seuchen,'" works embracing the 
history of pestilences over the whole globe ; and Villalba's 
' Epidemiologia EspaSola,' and Ilmoni's ' Bidrag till Nordens 
Sjukdoms Historia,' which treat of particular regions. The 
first to take up the pathological standpoint in the history of 
pestilences was Hensler, the author of the admirable works 
' Yom abendliindischen Aussatze,'^ and 'Geschichte der Lust- 
seuche.'* Thereafter followed numerous writings on the 
history of syphilis, smallpox, malignant sorethroat, typhus 
fever, scarlet fever, and miliary fever ; later came Ozanam^s 
' Histoire medicale gener. et particul. des maladies epide- 

' 2 vols., 8vo, Hartford, 1799 ; Engl. Ed., London, 1800. 
- 2 vols., 8vo, Tubingen, 1823. 
^ i2mo, Hamburg, 1790, 
* Vol. i, i2mo, Altona, 1783. 


miques/-^ a work embracing the history of all pestilences ; 
then the numerous classical monographs of Hecker^ ' Uebor 
die Justinianeische Pest/ ' Der schwarze Tod in 14 Jahrhun- 
dert/" 'Die Tanzwuth/^ 'Der englische Schweiss/* 'Die 
epidemischen Krankheiten der Jahre 1770-1772-' (in his 
history of modern medicine) . Lastly we have the ' Ges- 
chichte der epidemischen Krankheiten/^ of Haeser, an 
excellent work in every respect, in which the author^ with a 
correct appreciation of scientific and practical needs, has 
endeavoured to do justice to the chronological and patho- 
logical standpoints equally. 

While one fully recognises the diligence in compilation 
which runs through many of the above-named works, and the 
great merits of their authors in arranging and critically 
sifting the mass of material, and while one takes due account 
of the results to which these investigations have led, yet it is 
impossible not to feel that they are but the partial labours of 
pioneers, which we may utilise, in a measure, in our endea- 
vours to reach the goal of all historico-pathological and 
geographico-pathological inquiry. The full aim and object 
of such inquiry is to exhibit the particular circumstances 
under which diseases have occurred within the several 
periods of time and at various parts of the globe ; to show 
whether they have been subject to any differences, and of 
what kind, according to the time and the place ; what causal 
relations exist between the factors of disease acting at 
particular times and in particular places, on the one hand, and 
the character of the diseases that have actually occurred on the 
other ; and finally to show how those diseases are related to 
one another in their prevalence through time and through 
space — a task, the high importance of which for the doc- 
trine of special diseases, for etiology and for hygiene, cannot 
well be misunderstood or called in question. 

^ 2ud ed., 4 vols., 8vo, Paris, 1835. 

" Berlin, 8vo, 1832, re-edited by Hirsch, Berlin, 1S65, Engl, transl., by 
Dr. Babington, i2mo., Lond. 1833. 

^ 8vo, Berlin, 1832. 

* Svo, Berlin, 1834. 

^ Vol. ii of the ist and 2nd ed., and vol. iii of the 3rd ed. (1880 — 82), of 
his ' Lehrbuch der Geschichte der Medicin und der epidemischen Krank- 


The execution of this task demands obviously, that there 
shall be a blending of all the points of view previously taken 
up in historico-pathological and geographico-pathological 
inquiry ; it demands an extension of the view over the whole 
field of pathology, and a method of handling whereby the 
subject investigated may be brought into direct relation 
with the doctrines of disease. In the present work, which 
may haply justify the title of a '^ Historico-Geographical 
Pathology " that I have chosen for it, I have striven after the 
attainment of this end in so far as the literary materials at my 
disposal permitted, and in so far as the scientific or practical 
interest of the several forms of disease seemed to require. 

In arranging the subjects treated of in this work I have 
followed the order at present in general use in the classifica- 
tion of disease. I accordingly distinguish : 

(i) Acute infective diseases. 

(2) Chronic infective and constitutional diseases. 

(3) Diseases of organs. 

I adopt this division without wishing in any way to prejudge 
or do violence to the facts ; and I do not forget that in an 
inquiry like the present, it is of less consequence to carry 
out a strict system (which is indeed not altogether prac- 
ticable owing to the very partial kind of insight that we have 
into many of the processes of disease), than to assign 
definite limits to each of the subjects of investigation. 


§1. Influenza takes a pi'ominent place among the acute 
infective diseases by reason of its wide prevalence in space 
■and in time ; tlie history of the disease may be followed into 
the remotest periods from which we have any epidemiological 
record at all, and its geographical distribution, in so far as 
we may trust the information before us, extends over 
the whole habitable globe. The leading position of influenza 
among the epidemic diseases makes it desirable that we 
should have a survey of the influenza epidemics hitherto 
known to have occurred ; and I have, in the following tabular 
statement, drawn up a survey of that kind embracing the 
period from 1173 to 1875. Beyond the year 11 73 the epi- 
demiological data, although they certainly relate to influenza, 
bear a stamp too little characteristic to make them likely to be 
useful for the following inquiry ; and in later periods as well, 
all those epidemics are left unnoticed which have been 
erroneously designated by the chroniclers as influenza, and 
which we must set down as simple bronchial catarrhs widely 
prevalent at the same season. 

•Chronological survey of epidemics of influenza according to 
records existing from the years 11 73 — 1875.^ 


Season of the 

Area of Epidemic Prevalence. 



Italy {i}. Germany (2). England (j). 


August . . 

Italy and France (1). 


March . . . 

Italy (i). 


January . . 

Italy (I ). 

France: Montpellier (2). 


March . . 

Germany (3). 


• • • • • 

Germany: Saxony and Thuringia (r). The 
Netherlands : Flanders (2). 


France : Paris ( i ). 

' The references to the literature are collected at the end of the section ; 
the numbers placed in brackets beside the names of localities refer to the 
authorities cjiven there. 



Season of the 

Area of Epidemic Pi-evalence. 

1 + 1 + 

January . . 

Italy: Bologna (i), Forli (2), Yenice (3), 
Florence (+). 


February . . 

France : Paris (5). 


September . 

France : Paris (i). 


General diffusion in Europe (j, 2). 


July *. '. '. 

Italy : Milan (3). 


August . . 

France (+). 
England (5). 


General diffusion in Europe. 


July .* '. '. 

Sicily (i). 


August . . 

Italy (2) : Padua (3), Lombardy (+). Dalma- 
tia (2). Switzerland (5). 


September . 

France (6) -. Poitiers (7), Montpellier (8), Nis- 
mes (9). 


October . . 

Netherlands: Harderwyk (10), Alkmaar (n). 
Spain (12I. 


Autumn . . 

General diffusion in Italy (i, 2, 3). 


General diffusion over the East, in Africa and 
in Europe (1, 2,3,4,5). 


June . . . 

Sicily (6, 7). Netherlands : Delft (8). 


July . . . 

Italy (6, 9). France (10, 11). Spain (12). 


August . . 

Italy (6, 7, 13). Portugal (13). Spain (13a). 
Constantinople (7). Germany : Augsburg 

Germany : Rhine Districts (15), Helmstadt ( 1 6), 


September . 

Silesia (17). Hungary (7). 


October . . 

Germany: Saxony (i+, 18, 19), Baltic Coasts 
(7,20). Netherlands: Alkmaar (8). 


Nov. & Dec. 

Denmark, Sweden, Livonia (7). 


Germany (i, 2). 


General diffusion (i). 


June . . . 

France (2). 


July . . . 

Italy: Venice, Rome, &c. (i). 


September . 

Italy (i). 


Winter . . 

Italy (i). Gei-many: Strasburg (2). 


Spain (i, 2). 


Summer . . 

North America : Massachusetts, Connecticut 
(3). This epidemic, the first that is known 
to have occurred in the Western Hemisi^here, 
is believed to have spread (according to (+)) 
to the West Indies and South America (as 
far as Chili). 


June . . . 

North America : New England States ( i ). 


January . . 

Italy and France (i). Germany : Shores of the 
Baltic (2). 


April . . . 

England: London (3). 


September . 

Germany in wide diflfusion : Leipzig (i). 
France (2). 


October . . 

Austria (3). Hungary (4). England : London. 


May . . . 

England: London (i). 


July . . . 

Ireland: Dublin (i). 



Season of the 

Area of Epidemic Prevaleuce. 


Oct. & Nov. . 

General diffusion in Great Britain, tlie North 
of France, and the Netherlands (i). 


General diffusion in Italy, France, Belgium, 
Germany, and Denmark. 


Jan. & Feb. . 

Italy : Rome, Florence, Milan, Turin, &c. (1,2). 


April . . . 

Germany: Berlin (3). Belgium (i). 

Summer . . 

Denmark: Copenhagen (4). 


June . . . 

Denmark : Copenhagen (i). 


July . . . 

Germany : Holstein (2), Jena (3), &c. 


August . . 

Germany : Augsburg (4). 


September . 

Germany: Tiibingen (5). 


December . 

Italy: Turin (6). 

1729 — 30 

April . . . 

Russia: Moscow (i). 


September . 

Sweden (i). 


October . . 

Germany : Vienna (2), Upper Silesia (i). 


November . 

Germany : Eisenach (3), Niirnberg, Regens- 
burg (5), Breslau (4). England : London (6), 
Plymouth (7). 


December . 

England : York (8). Switzerland : Lucerne, 



Switzerland : Lusanne (9). Italy : Lombardy, 
Bologna, Romagna, Toscana (10, 11). 
France : Paris (1). 


February . . 

Germany: Halle (12), Rhine Districts (11). 
Switzerland: Rhaetian Alps (9). Italy: 
Rome, Florence, Monte Casino, &c. (u). 


March . . . 

Italy : Naples, Sicily (u). Spain (13). 
Iceland (14); the first well- authenticated in- 
fluenza epidemic there. 

1732 — 33 

Seemingly a general diffusion over the globe. 


October . . 

America : New England States, Newfoundland, 
West Indies, Mexico, Peru (15, 18). 


November . 

Russia. Poland. Germany: Eisenach (1). 



Germany: Coburg (2). Switzerland: Basel 
(6). Scotland: Edinburgh (10). Isle de 
Bourbon (17, 18). 


January . . 

England : London ( 10, 1 2), York (i 3). France : 
Paris (8, 10), Dijon (9). Netherlands: Ley- 
den (4), Harderwyk (3). Italy : Milan (14). 


February . . 

England: Plymouth (i i). Italy: Leghorn (10). 
Spain": Madrid (10). 


March . . . 

Italy: Naples (19). 


April . . . 

Majorca (16). 


Iceland (i). 

1737 — 38 

November . 

England: Plymouth (i). North America (2). 


December . 

West Indies : Barbadoes (2). 


January . . 

General diffusion in France (3). 


January . . 

Germany : Coburg (i), Erfurt (2). 


February . . 

Germany: Dresden, Coblentz (i). 


October . . 

Switzerland (2). Italy: Brescia (i). 


November . 

Italy : Milan, Venice (i). 


December . 

Italy : Bologna (i). 




Season of the 

1742 — 43 January . 

February , 

Marcli . . 

April . . 
1757 — 58 'September 

May . . 

October . 

Dec. — May 

February . 
March . . 

1761 — 62 





April . 

June . 
July . 




1772 iFebruai-y . 

1775 — 76 March. . 

„ June . . 

,, {September 

October . 



January . 

1780 — 81 January . 

March . . 

Area of Epidemic Prevalence. 

Italy : Rome, Pisa, Leghorn, Florence, Genoa 


Italy: Naples, Sicily (i). France: Paris (6), 

and in general ditt'usion. 
Netherlands: Leyden(3). Belgium: Brussels 


England: Plymouth (5). 

General diffusion in North America (i). West 
Indies : Barbadoes (2). 

France: Bo\ilogne(9). 

France : Lille (8), Paris (7). 

Scotland: Edinburgh (4). 

Scotland : Fife, St. Andrews, Perth, Inverness, 
Aberdeen, &c. (4, 5, 6). England: York (3). 

General diifusion in North America and West 

Germany: Bi-eslau (10), &c. 

Germany: Vienna (3, 4) and Hungai-y. Den- 
mark : Copenhagen (13). 

Germany : Magdeburg, Hamburg (10), Bremen 
(4). Great Britain : London (10, 11), Edin- 
burgh (12). Italy (2, 3). 

Ireland: Dublin (13). 


Fleet in the 

North America and 

France : Alsace (6, 14), Lille (8) 

France : Nismes (6), 
Mediterranean (10). 

France : Gusset (9). 

Widely diffused over 

North America: New England States (10) 
Germany : Eisenach (i), Giessen (2). 

England : London (7). 

France: Lille (4). 

France : Paris (3). 

France : Provence (5), Normandy (6), Italy : 
Toscana (12). 

Italy : Naples (8). 

Spain : Madrid (9). Cayenne (11). 

North America (i). 

Germany: Clausthal (i). 

Germany : Vienna (2). 

Italy: Naples (10). 

Italy: Pisa (10). France: Paris (3), Bourges 
(5), Bruyeres. England: London (7), Tork 
(9). Ii-eland: Dublin (11). 

France: Bordeaux, Lyons, &c. (3). Wide dif- 
fusion in England (8, 9). 

France : Normandy (4), Montpellier (6). Eng- 
land: Devonshire (9). 

France : Martigues, Poitiers, Brest (4). 

France: Paris (3) and general diffusion (2). 

France : Lorraine (4). Italy : Milan, Turin, 
&c. (s). Germany : Heidelberg (i). Brazil (6). 




Season of the 

1780 — 81 December 
„ February . 
,, March . . 

1781—82 . . . . 
,, Autumn . 
,, December 
,, January . 
„ Febi'uary . 

Marcb , 
April . 




July . 








October . 

1789 — 90 

October . 



Area of Epidemic Prevalence. 

Russia: St. Petersburg (7). 

Russia: Wilna (7). 

North America (8). 

General diffusion over the Eastern Hemisphere. 

China, British India (31, 31). 

Siberia. Russia: Kasan (5, 31). 

Russia : St. Petersburg (4). 

Russia: Reval (4, 36), Riga (4, 3). Finland: 
Lovisa (4). Germany : East Prussia, Tilsit, 
Braunsberg, &c. (7). 

Germany: East Prussia (7), West Prussia, 
Pomerania (i). 

Denmark (4, 20, 25). Germany: Nordlingen 
(4), Erfurt (13, 14), &c. (1,2, 12). Sweden (4). 

England : Newcastle (28, 31). Hungary : Mis- 
kolcz (23). 

Germany : Prague (20 — 22), Hamburg (9), 
Clausthal (10), Lauterbach (11), Mayence (15), 
Giessen (16), Vienna (22), Niirnberg (17), and 
other places in Central and Southern Ger- 
many. England : London (27, 29, 30), 
Devonshire (34), and various parts of Suflfolk, 
Surrey, &c. Scotland : Edinbui'gh and else- 
where (23). 

Germany (South) : Freiburg (19), &c. Nether- 
lands (27). England and Scotland generally 

(2, 34)- 

France: Alsace, Flanders, Brittany {4, 37, 38), 
Paris (36), &c. Italy: Sinigaglia, Ancona, 
Urbino, Spoleto, Rome, Florence, Parma, 
Modena, Bologna, Venice, Pavia, Verona, 
Milan (4, 39 — 42). 

France : Orleans, La Rochelle, Montpellier, &c. 

Spain : Madrid, &c. (4, 43). 

Russia : St. Petersburg, Kherson, Poland (8). 

Germany: Vienna (3). Hungary : Miskolcz (2). 

Denmark: Copenhagen (11). 

Germany: Munich (i). England: Plymouth (7). 

England : London, Kent, Dover (5), Bath (4), 
Manchester (6). 

Englanci and Scotland : Cornwall, Montrose (5). 
France: Paris (9). Italy : Padua and other 
places (12). 

France: Lille (10). Italy (12). 

Italy: Verona, Brescia, Mantua (13). Switzer- 
land : Geneva (14). 

General diffusion over the Western Hemi- 
sphere (i, 3). 

Georgia (4), New Tork (i, 2). 
Philadelphia (3), New Eng- 
West Indies : Jamaica (6). 
Massachusetts (4). West In- 

North America : 
North America : 

land States (i) 
North America : 

dies (3, 5). 
Nova Scotia (4). 

South America (3). 




Season of the 

Area of Epidemic Prevalence. 

1789 — 90 

Spring . . 

North America : Albany, Vermont, Boston, 
New York, and various other places anew (i). 


Nov. & Dec. . 

General difi'usion in U.S. of America. 

1800 j 

North-eastern parts of Europe. 


October . . 

Russia: Moscow (2). 


November . 

Russia : Vologda, Archangel (2). 



Russia : Riga, Mittau (2), Kasan, St. Peters- 
burg (i), Ukraine, Volhynia, Podolia (10). 


January . . 

Galicia: Lemberg (10). 


February . . 

Poland: Warsaw (11). Germany: Province of 
Prussia (2). 


April . . . 

Germany: Vienna (9), Posen (2). 


May . . . 

Denmark: Copenhagen (12). 

1800 1 

September . 

China (14). 


October . . 

Germany: Liineburg(4). France: Lyons (13). 


November . 

Germany: Altenburg(5), Paderborn(6), Donau- 
eschingen, Sigmaringen. 



Germany: Stuttgart (8). 


January . . 

Germany: Gorlitz (7). 


Brazil: Rio Janeiro (i) 

1802 — 3 

Winter . . 

Very extensive diifusion in France (2, 3, 4, 14, 
.15, 16, 17). 


January . . 

Germany: Stolberg-on-Rhine (7). Italy: Mi- 
lan (18, 19). England: London, kc. (10, 
II, 13). 


February . . 

Germany: Frankfort-on-Main (5), Cologne (6), 
Mayence (8), Hanau(23). Widely spread in 
Britain (12, 13, 22). 


March . . . 

Universally in Britain (12, 13). Italy: Genoa 
(20), Verona, Padua, Modena (21). Switzer- 
land: Geneva (24). 


April . . . 

Germany: Paderborn (9). Britain (13). 


Iceland (i). 

1805 — 6 

Winter . . 

Generally in West Indies (13); in St. Bartho- 
lomew in November. 



Spain: Catalonia (12). 


September . 

Russia : Wilna (3). 


November . 

Germany: Erlangen (2). France: Paris (4, 6, 
9, 10). Narbonne (7). 


January . . 

France: Versailles (5), Lyons (15). Italy: 
Lucca and all Northern Italy (11, 14). 


General in North America (i). 


February . . 

Massachusetts (2). 


Spring . . 

New England States (i, 3, 7). 


October . . 

Western States (i). 


November . 

Scotland : Edinburgh (3). 


December . 

England: London (i), Nottingham (2). 


January . . 

England : Newcastle (4). 


General diffusion in Brazil (i). 

1815— 16 

Autumn "; 
and Winter _i 

General diffusion in North America (i)- 


September . 

Boston, U.S.A. (i). 




Season of the 

1815 — 1 6 October . 
j Winter 
Febniary , 

1824 — 25 

October . 
I November 

1826 . . . . 
,, January . 


Febniary . 

May . . 

„ January . 
,, February . 
1830 — 32 . . . . 



January . 

January . 

February . 
Marcb . . 
April . . 
May . . 

June . 

July . . 


January . 

Area of Epidemic Prevalence. 

New York (3). 

Pennsylvania (2). 

Soutli Carolina (i). Iceland (5). Widely spread 
in Brazil (4). 

In the Northern States of the Union (i). 


New York. 


Widely spread over the Western Hemisphere. 

U. S. of Amei-ica : general in the Southern 
States, Georgia (i), Alabama (3). 

U. S. of America : general in the Atlantic 
States as well as in the Eastern, Northern, and 
Western (i). 

Generally in Mexico (2). 

Extensively in Peru (4). 

Generally diffused in Siberia and Eastern 
Russia (i). 

Siberia : Tobolsk, Tomsk. 

Russia: Perm. 

General diffusion over the Eastern and Western 

China (i, 49). 

Manilla ( I ). Polynesia : Navigator's Islands (47). 
probably for the first time. 

Russia: Moscow. 

Russia : St. Petersburg (4). East Indies : 
Borneo, Sumatra (2). 

Russia : Courland (5), Dorpat (5). 

Poland: Warsaw. East Indies : Java (2, 3). 

Germany: East Prussia (n), Silesia (15). 

Germany: Danzig (10), Brandenburg (12, 13), 
Berlin (51), Magdeburg (14), Kingdom of 
Saxony (16, 17), Duchy of Nassau (54), Rhine 
districts, in pai-ts (18,19), Homburg, Bamberg 
(27), Bohemia (29, 31), Vienna (30), Wiirtem- 
berg, in parts (2 5). Finland (7). Denmark (8,9). 

Germany : Rhine districts, Cologne (20), Hanau 
(22), Mayence (23), Ansbach (28), Heidelberg 
(24), Wiirtemberg, in parts (25). Belgium 
(53). -France: Paris, &c. (34 — 36). Sweden, 
in parts (7). Scotland : Glasgow. England: 
Douglas, Isle of Man (39). Further India: 
Singapore (3). East Indies (3a). . 

Germany: Aix (21), Wiii'temberg (25, 26). 
Switzerland: Geneva (32, 33). France: Tou- 
louse(37). England: London,&c.(38). Sweden, 
in parts (7). Further India: Penang (3). 

Italy: Rome (41, 42), Toscana (48). U. S. of 
America : New Jersey (44), Philadelphia (50). 

Italy: Naples and Sicily (40, 43, 48, 52). 

Spain : Gibraltar. North America : Philadel- 
phia (44), apparently a revival of the previous 







Season of the 

April . 

March . 

April . 




June . . 

July . . 


Januaiy . 
February . 

October . 


Area of Epidemic Prevalence. 

Nortb America : Georgia (45). 

India: Indore, Meerut, and other places (46). 

India : Bangalore (46). 

General diffusion over Western Asia, North 
Africa, and Europe. 

Russia : Moscow, Perm, Kasan, St. Peters- 
burg (3), Riga (4). 

Russia : Odessa (2). Galicia : Brody (63). 
Germany : Memel (24). 

Egypt (1,4). Syria (4). Poland : Warsaw (i 5). 
Germany: Prov. Prussia (15 — 19, 24), Posen 
(24), Oppeln, Breslau (22, 23), Prov. Branden- 
burg and Berlin (25 — 33), Liineburg (39), 
Bohemia (60). Denmark: Elsinore (9J. 

Germany: Greifswald (20, 31), Liegnitz (22), 
Prov. Saxony (34), Hamburg (36). Kingd. of 
Saxony (40 — 42), Jena (43), Fulda (44), Hom- 
burg (56), Bohemia (61, 62), Lower Austria 
and Vienna (64 — 67), Upper Austria and 
Linz (68, 69). Hungary: Pesth (74, 75). 
Denmark: Copenhagen (9 — 13), Fiinen and 
Jutland (9\ Alborg (14). France: Paris 
(79 — 82), Bordeaux (85), &c. Britain: Lon- 
don (93, 94), Birmingham (95), Edinburgh 
(96), Armagh (97). 

Germany: Schleswig-Holstein (35), Bremen 
(37), Marburg (45), Rhine Province (46 — 49), 
Duchy of Nassau (100), Heidelberg (50), 
Wiirtemberg (51), Munich (53, 54), Weis- 
senberg (55), Wiirzburg (57, 58), Kirchenla- 
mitz (59), Tyrol (70), Styria (72), Laibach 
(71). Dalmatia (73). Italy : Lombardy, 
Venetia (86 — 88, 98). 

Germany: Ditmarschen (35), Osnabriick (38), 
Wiirtemberg, &c. (51). Netherlands: Am- 
sterdam (99). Italy : Modcna, Romagna, 
Ancona (90 — 98). 

Germany: Sigmaringen (52). Italy: Novara 

Switzerland : Aarau (76), Ziirich (77), Bern (78). 
France: Dpt. de la Moselle (84). 

Italy: Naples (91, 92—98), Sicily (98). 

Cayenne (i). 

India: Calcutta (3). 

Brazil : Rio de Janeiro (2). 

Considerable diffusion in the 

Australia: Sydney (i). 

South Africa : Cape Town (2) 
Further India: Penang (104). 

Russia: St. Petersburg (3). Sweden (4). Den- 
mark : Elsinore, Copenhagen, &c. (5, 8). 
Germany : Greifswald (10), Province of 

Eastern Hemi- 

Java (96), 






1 841 




Season of the 

February . 

March . 

July . . 
February . 

January . 

February . 
March . , 

April . . 

January . 
Marcb . , 

March . . 

April . , 
May . 
Summer , 
June . , 

July . 

Area of Epidemic Prevalence. 

Brandenburg, Berlin 
various places (46). 
Egypt, Syria (91, 92). 

(16, 17). England, at 
Denmax-k : Bornholm, 

Viborg, &G. (2). Germany : Prov. Prussia 
(9), Schleswig-Holstein (11), Hamburg (12 — 
15), Breslau (18), Peitz (19), Kingdom of 
Saxony (20, 21), Fulda (23, 24), Hesse (25, 27, 
28), Cassel (99), Rhenish Prussia (30, 32, 33). 
Wiirtemberg (34). England (46) : London 
(47, 48), Sidmouth (103), Birmingham (49), 
North Shields (50), Liverpool (102). Ireland 
(51) France: Paris (54 — 65), Strasburg (66), 
llennes (68), Nancy (69), Bordeaux (81), &c. 
Netherlands (97)- Switzerland: Geneva (loi). 

Germany: Kingdom of Saxony (21), Jena (22), 
Emden (29), Rhenish Prussia (30, 31), Nassau 
(98), Wiirtemberg (34), Stuttgart (3 5), Kreuz- 
wertheim, Bavaria (37), Lower Austria (38 — 
41). Switzerland: Solothurn, &c. (43). Bel- 
gium (95): Antwerp (53). France: 
la Moselle (70), Lyons (71 — 75), Dijon (80, 81), 
Narbonne (76), Toulouse (77), Dpt. Tarn et 
Garonne (78), Montpellier (82). Northern 
Italy: Turin (83), Brescia (84), &c. (85—88). 
Spain and Portugal (100) : Lisbon (89, 90). 

Germany: Wiirtemberg (34), Sigmaringen (36), 
Salzburg (42). Switzerland: Uster, Hongg, 
Bern, &c. (43—4 5)- 

Faroe IsVands (5). Mexico (93). 

Isle de Bourbon (i). Iceland (3, 4). 

Australia: Sydney. New Zealand (5). 

Abyssinia : Tigre (2). 

Germany: Prov. Prussia (i), Halle (2), King- 
dom of Saxony (3), Liineburg (7). 

Germany : Peitz (4), Fulda (5), Jena (6). 

Germany : Province of Westphalia (13), Nassau 
(13). Vienna (10). Hungary: Pesth (9). 

Germany: Rhenish Prussia (8). Ireland: Dublin 
(u, 12). 

Belgium (i), 

England: London (4), Tork (5), &c. 

France: Paris (2, 3). 

General diffusion in Egypt (6). Chili (7). 

Germany: Berlin (5), Westphalia (3). Eng- 
land: London (4). Iceland (11). 

France: Paris (5). 

North Siberia (i). 

General diffusion in North America (9). 

U. S. of America : New England States, New 
York, Western States (8). 

U. S. of America: Pennsylvania (10), Central 
and Southei'n States (8). Virginia (12). 

U. S. of America : S. Carolina (8). 





1846 — 47 




Seiison of the 

January . 
February . 
January . 
Winter . 

February . 

March . . 

Augrust . 

October . 



Januai-y . 
Oct. & Nov. 

January , 

February , 
March . . 

1853 January 


May . . 
January , 

Area of Epidemic Prevalence. 

.'Germany: Rhenish Prussia (1), Westphalia 
I (a), Nassau (7). England: Cheshire (3). 
.'France: Dpt. AUier (4). Switzerland: Geneva 

I (8). 
.Russia: St. Petersburg (5). 

[ Wide diffusion in Cayenne (6). New Zealand (9). 
.Germany: Regensburg, Minden (i). Switzer- 

I land : Zi'irich, Bern (2). 

. England: Richmond (i). Denmai-k (2I. Bel- 
gium (4). Switzerland: Basel (5). France: 
Paris (10). 

Sv/itzerland : Bern (7). France: Toulouse (8). 
Russia: Jaroslav (6). 

Russia: St. Petersburg (3). 

Turtey : Constantinople (9). 

Generally diffused over the Eastera Hemisphere. 

France: Rennes (23). 

France: Lyons (24). Denmark: Copenhagen 
(25). Germany: Bohemia (2). 

Germany: Bohemia (2), Schleswig-Holstein (i), 
Wiirtemberg (4). Denmark (5). Nether- 
lands (6) : Amsterdam (26). France : Mar- 
seilles, &c. (9). Britain: London (10, 11, 12), 
York (13), Edinburgh (15, 16, 27). 

Germany: Erlangen (3), Duchy of Nassau (28). 
Netherlands (6, 7). Switzerland (8). France: 
Puy de Dome (17), Paris (29). Northern 
Italy: Genoa, Nice, Alessandria, &c. (9. 18, 
19). Spain: Barcelona, Madrid (9). Greece, 
Egypt, Algiers (20). North of Scotland (14). 

Germany: District of Holzen, Bavaria (30). 
Belgium : Liege (31). Southern Italy : Naples 
(9). Hawa'ian Islands (32). 

West Indies: St.Yincent (i), Santa Cruz, &c.(2i). 

Generally diffused over the Western and 
Eastern Hemispheres. 

West Indies: Martinique (i). America: Peru 
and Chili, spreading from Lima along the 
coast to Valparaiso (2). 

North America : California (3). Germany: Osna- 
briick (4), Duchy of Nassau (5). Prague (13). 

Germany: Upper Harz (6). Sweden (7). 

Germany: Bavaria (8). France: Paris (9, 10). 
Italy: Asti (11). Egypt (12). 

Australian Continent and Tasmania (i). South 
Amei-ica : Peru and Chili, as in previous 
year (2). 

Cape Colony (i). 

Faroe Islands (2). 

Bavaria, in several departments (i). 

General prevalence in Europe. 

Russia: St. Petersburg (i). Germany: Ba- 
varia (2), Wiirtemberg (3). Netherlands (4). 
Belgium : Liege (5). Italy : Naples (6). 






Season of the 

March . 
May . 
June . , 

February . 
July . , 

Area of Epidemic Prevalence. 

August . 


January . . 

May . . . 

i860 June& July . 

1861 December 

1862 January . . 
April . . . 
May . . . 

1863 — 64iWinter . . 

,, [February, 
1866 1 March . , 



May . . . 
Febiliary . . 
March . . . 
April . . . 
Jan. — March 

1874 — 75 Winter 

Germany: Duchy of Nassau (7). 

Iceland (8). 

Brazil : Rio de Janeiro (9). 

Faroe Islands (i). 

Iceland (2). 

Wide diffusion over the Western and Eastern 

Central Amenca: Panama (i). 

West Indies (2, 3). South America: Coasts of 
Chili and Peru (3). British North America : 
Vancouver's Island (3). 

Russia: Courland (+), St. Petersburg (5), Sa- 
mara (6). Germany : Duchy of Nassau (7), 
Wiirtemberg (8), Bavaria (9), Bohemia (17). 
Belgium (10). France generally (n): Paris 
(12), Strasbiirg (13), Lyons (14.). 

Italy: Naples (15). 

Faroe Islands (16). 

Australian Continent and Tasmania (x, 2). 

North America: Philadelphia (i). 

Bermudas (i). Netherlands: Rotterdam (2). 

Cape of Good Hope (3). 

Iceland (4). 

New Caledonia (i). France: Paris and else- 
where (2). California, along the Pacific 
coast (3). 

Switzerland : Canton Zurich (4). 

France: Paris, Dpt. de I'Aisne (1), Bains en 
Vosges (2). 

England: London (3). 

Reunion and Mauritius (4). 

France: Paris (1,2, 3), Strasburg (4). 

Germany: Stuttgart (5). 

Belgium : Ghent (6). 

Turkey: Constantinople (i). 

Cape of Good Hope (i). 

Universally in North America : Pennsylvania, 
Ohio, Virginia, Illinois, Iowa, Michigan, 
Wisconsin, Minnesota, Missouri, Alabama, 
Louisiana, Texas, and other States (i). 

Widely spread over the Western and Eastei-n 
Hemispheres. North America : Texas, New 
York, South Carolina, Ohio, Iowa, and other 
States (1). Germany : Austria (2). France: 
Paris, Bordeaux, Toulouse, Havre, &c. (3), 
Dpt. des Ardennes (4), Lyons (5). Sweden (6). 


§ 2. Always occurs as an Epidemic or Pandemic. 

Influenza always occurs as an epidemic disease, whetliei 
within a narrow circle or even confined to particular 
places, or in general diffusion over wide tracts of country, 
over a whole continent, and, indeed, not rarely over a great part 
of the globe as a true pandemic. It is in this last respect 
that influenza takes an exceptional place among the acute 
infective diseases ; no other of them has ever shown so pro- 
nounced a pandemic character as influenza. In estimating 
the distribution in space to which the disease has attained 
in the several epidemics, it should be kept in mind that, 
for many of them, the records available are but defective 
ones, not warranting definite conclusions as to the area of 
epidemic distribution. And this holds good not only for 
past centuries, but still more for the decades just expired 
and in particular for the pandemics of the years 1857-58, 
and 1874-75. The interest in the subject had become, 
exbausted for the greater number of observers and chroni- 
clers, or, at all events, it lias not been aroused except in the 
case of especially severe and destructive epidemics ; and one 
may therefore premise that, in many cases in which there 
seem to have been only isolated outbreaks of the disease at 
various points, there have been intermediate outbreaks not 
recorded ; so that the conclusion as to the extent of the epi- 
demic is not altogether reliable. Beyond doubt, influenza 
bas prevailed in tropical and sub-tropical regions much ofteuer 
and mucli more widely than the somewhat scanty information 
from those parts would lead us to believe ; and it is therefore 
justifiable to surmise that the disease as a pandemic has even 
greater importance than we might ascribe to it fi'om the data 
before us. 

In truly pandemic form, we meet with authentic influenzas 
in the years 1510, 1557, 1580, 1593, 1732-33, 1767, 1781-82, 
1802-3, 1830-33, 1836-37, 1847-48, 1850-51, 1855, 1857-58, 
and 1874-75 ; in several of these pandemics, the disease 
extended not only over the Eastern Hemisphere, but it reached 
also to the Western ; in others it remained limited to the 
former ; while pandemics are known to have occurred exclu- 


sively in the Western Hemispliero in the years 1647, ^737-3^- 
1757-58, 1761-62, 1789-go, 1798, 1807, 1815-16, 1824-26, 
1843, ^^^ 1873. Widely prevalent influenzas over large 
tracts of country occurred in Germany in 1591, 165S, 1675, 
1800, 1841, and 1844; in Franco in 1737, 1775, 177O; in 
the West Indies in 1805. 

Among isolated outbreaks of the disease, the often observed 
epidemics on hoard ship are especially interesting. In several 
cases of the kind, the crews were attacked, and that too just 
as suddenly and without warning as when influenza appears 
on land, while the ships were lying in port or cruising off the 
€oast, no trace of the disease having shown itself either before 
or after in the same region ashore. Among the observa- 
tions to that effect may be mentioned : that of Pop,^ on an 
epidemic in February, 1856, on board a Netherlands frigate 
in the harbour of Macassar, in which 144 out of a ship^s 
company of 340, fell ill in a few days ; the observations by 
surgeons of the English navy^ on the breaking out of influenza 
in August, 1856, in the harbour of Rio de Janeiro, and, in 
October of the same year, in the harbour of Callao ; those by 
surgeons of the German navy^ on the appearance of the disease 
on board a ship of war in April, 1875, in the North Pacific (38° 
N., 149E.) a few days after leaving Yokohama, and on board 
another ship in July of the same year in the Gulf of Pe- chili, 
China ; and lastly by Chaumeziere,* on the epidemic of 
influenza on board a French frigate in February, 1863, four 
days after leaving the harbour of Goree, Senegambia : not 
a trace of the disease had shown itself in the town ; while 
another ship of war, that left Goree two days earlier, and 
took the same course, arrived in the harbour of Brest without 
having had a single case of^ influenza on board. In other 
and still more interesting cases, the disease has appeared, 
at a time when it was generally prevalent on land, 
among the crews of ships on the high seas which had not 
previously communicated with an infected shore ; and those 

1 'Nederl. Tijdschr. voor Geneesk,' 1S59, iii, 22. 

- ' Statist. Eeport on the Health of the Navy for the year 1856,' p. 100. 

^ ' Statist. Sanitatsbericht iiber die kaiserl. deutsche Marine f iir das 
Jahre 1875-1876,' 22. 

■• Chaumeziere ' Fievre catarrhale, epidemie observee a bord du vaisseaii 
le Duguay-Trouiu aus mois de Fevr. et Mars, 1863,' Paris, 1S65. 


outbreaks befell at the same time as the outbreaks of influenza 
on the coasts neai'est to the position of the ships. Thus, in 
September, 1781, influenza attacked the crew of an East 
Indiaman on the voyage from Malacca to Canton, so generally 
that scarcely a single person escaped ; when they left 
Malacca, the disease was not prevalent there, but when they 
arrived at Canton it transpired that their outbreak on board, 
in the China Sea, had happened at the very time when the 
disease was showing itself with equal intensity at Canton.^ 
On board the fleet of Admiral Kempenfeldt, which had sailed 
from Spithead on the 2nd of May, 1782, influenza broke out 
at the end of the month with such intensity that the ships 
were obliged to return to port in the second week of June ; 
they had not been in communication with any part of the 
coast, but had been cruising on the high sea between Brest 
and the Lizard. Similar observations were made, at the time 
of the universal prevalence of influenza in 1837, on board 
English ships of war cruising on the coasts of Spain and 
Portugal, and in Indian waters.^ Eenault^ records an epidemic 
of influenza in 1847, on board a French mail steamer on the 
passage from Marseilles to Alexandria, coincident with the 
outbreak of the disease on the Mediterranean coasts. On 
board an English ship of war cruising on the coast of Cuba 
in 1 85 7, and holding no communication with the shore, the 
greater part of the crew fell ill of influenza ; it was after- 
wards ascertained that the disease had been prevalent during 
the very same time at Havanna, in Trinidad, and in other 
West India islands.* For the same year (1847) we have 
the following from the Pacific station •} " Influenza broke 
out in the Monarch while at sea, on the passage from 
Payta to Valparaiso. She had left the former place on the 
23rd of August and arrived at the latter on the last day of 
September. About the 12th of the month. . . seven 

' This fact, and the one that follows, are taken from communications by 
surgeons of the English nary, which are collected in Himly's ' Darstellung. 
der Grippe vom Jahre 1782, &c.,' Hanover, 1833, p. 8. 

" 'Statist. Repoi-t on tlie Health of the Navy for the years 1837 — 1843,'' 
ii, 8, iii, 7. 

3 ' Gaz. iled. de Paris,' 1856, 6S0. 

•• ' Eeport on Health of Xavy for year 1857,' 41. 

* lb. 69. 


men were placed on the sick list witli catarrhal symptoms, and 
during the following ten days upwards of eighty were added. 
On the arrival of the ship at Valparaiso, the place 
was healthy; but, in the course of a few days, some cases of 
influenza made their appearance, and very soon afterwards 
the disease extended over the whole town. . . The sur- 
geon further observes that the whole coast, from Yan- 
couver's Island southwards to Valparaiso, was visited by the 

§ 3. Mode of Progression. 

There have been two points which have always attracted 
the particular attention of those who have investigated 
influenza with reference to its time of outbreak and its 
range of diffusion : viz. iJeriodicihj in the recurrence of epi- 
demics or i^andemics ; and the order in which particular places, 
districts, or larger tracts of country have successively 
been invaded by the pandemic, or in other words, tlie progress 
of the disease in a definite line from east to west. As regards 
the first-named point, a glance at the chronology of influenza 
pandemics is sufficient to convince one that the assumption of 
•a definite periodicity in their succession is absolutely ground- 
less, and that any such regularity in the more isolated cases 
of its epidemic prevalence in various parts of the globe is in 
nowise capable of pi'oof.^ With apparently greater justice it 
has been inferred from the data of earlier observers, that there 
is a regular progress of the sickness from east to west. 
This notion is based upon an assumption, to my mind 
eri'oneous, that the separate portions of a great epidemic or 
pandemic of influenza stand' in a direct pathogenetic relation 
to one another, and that the causative agent, beginning at 
one point and radiating therefrom, has extended to ever 
wider and wider circles. It cannot certainly be denied that 

^ Finsen (' Jagttagelser angeaande Sygdomsforhold i Island.' Kjobenh. 
1874, 24) writes in this connexion respecting Iceland : " Those who rely 
upon the experience of former times assume that this infective disease breaks 
oiit every nine years, but that inexj)licable periodicity has not been kei^t up 
■in more recent times." 


some patidemics, regarded as a wliole, do afford evidence of the 
sickness travelling in tlie alleged direction, from east to west ; 
in other cases, however, the disease has gone in an opposite 
direction/ or it has travelled from north to south, or from 
south to north. Still less is there any definite track of sickness 
discoverable within the more isolated and smaller circles. 
Not uufrequcntly, as for instance in the pandemics of 1833 
and 1837, many countries taken together in a group liavo been 
smitten by the disease as if at one blow ; while, for particular 
localities situated within that area, there have been intervals 
of one or more weeks in the time of the influenza appearing ; 
and there are not wanting observations to show that the 
sickness had raged for a considerable time in one quarter 
of a town before it showed itself in the others. The larger 
number of facts is rather in favour of a radial lyrorjress of 
influenza, or a ^nogress by leaps and bounds, than of a 
linear progress ; ivhile, in a comprehensive revieiv of the facts, 
the direction is found to be sometimes to one point of the compass, 
sometimes to another. So that the extension of the disease 
in one single direction cannot be regarded as a peculiarity 
appertaining to influenza. 

A few facts from the histories of outbreaks may serve to 
elucidate the questions here raised. As early a writer as 
Baker^ says, with respect to the spread of the disease in 
England : " I have considered it worth while to inquire 
whether this epidemic catarrh has passed fi'om one part of 
our island to another in any definite line of progress ; whether,, 
in fact, it has travelled from east to west, or from northern 
localities southwards, or whether it has made the journey in 
the opposite order. But I have ascertained that it obeyed no 
law whatsoever, running its uncertain course in a somewhat 
desultory manner." In the epidemic of 1833, the disease in 
the department of Konigsberg, according to Richter^ " fol- 
lowed no definite geographical line, but attacked here one 
place there another, as if it had been leaping from island to 

1 Ghige thinks that he has discovered the spread of influenza previous ta 
the i7tli centuiy always to have been in a direction from west to east; but 
the scanty and in part unreliable data concerning the influenza pandemics of 
that period hardly warrant the formulating of such general laws. 

2 ' Opuscula medica,' Lond., 1771, 29. 
^ L. c, 120. 



island." In the epidemic of 1837, the districts of Denmark 
lying to the west suffered, according to Bremer (1. c), quite a 
month before those to the east. On the continent of North 
America, the extension of the disease is just as often from 
south to north (epidemics of 1761, 1789? 1826) as from north 
to south (epidemics of 1790 and 18 15), and not unfrequently 
(epidemic of 1843) it proceeds in an altogether irregular 
manner. In Greenland, where, as we shall afterwards see, 
epidemics of influenza have been often observed, the disease 
usually takes a course, according to the researches of Lange,^ 
from north to south. On the other hand, in Iceland, as Finsen 
remarks,^ influenza proceeds mostly from south to north ; 
that there are, however, considerable exceptions to this rule 
is proved by the epidemic of 1843, i^ which various points 
on the island were almost simultaneously attacked,^ and by 
that of the year 1856, in which the disease appeared first in 
the northern territory.* 

The evidence is just as scanty for any regularity in the 
length of time occupied in the extension of the epidemic from 
country to country or from place to place. Not unfrequently, 
as for example, in the pandemics of 1833 and 1837, there 
have been large tracts of country smitten as if at a blow ; in 
other cases, weeks and even months have passed before the 
disease extended to places even close at hand. 

In the pandemic of 1826 on the continent of North 
America, the first cases appeared in Georgia during the month 
of January, and the disease was prevalent in Boston as early 
as the beginning of February. On the other hand, the pan- 
demic of 1843 broke out first in New York in the middle of 
June, it appeared in the districts to the east of the lakes, as 
well as in the Central States, in July, and it was not until 
August that it appeared in the Southern States. In the 
epidemic of 1841, the disease prevailed in Prussia, Saxony, 
Hanover, and other states in January, while it showed itself 
first in Rhenish Prussia in April. In Greenland, it is usual for 
the beginning of the epidemic to appear in the northern 

1 ' Bemaerkninger om Gronlands Sygdomsforhold.' Kjobenh. 1864, 13. 
^ ' Jagttagelser angaaende Sygdomsf orholdene i Island.' Kjobenh. 1874, 25. 
3 Hjaltelin, 1. c. 
^ ' Sundhetscoll. Aarsbex'etning for 1856/ 66. 


parts of the country from February to April, middle Green- 
land being visited by it in May and June, south Greenland 
in August or sometimes as late as September. 

Finally, we have still to consider the circumstance, already 
adverted to, that there have been many remarkable ex- 
ceptions to the incidence of influenza universally at a given 
place. Although it is the rule for the disease to extend 
uniformly to the whole population of a place, thereby 
stamping influenza with a peculiarity which belongs to 
no other infective disease except, perhaps, dengue, yet 
the exceptions are numerous and worthy of notice. 
Thus Hamilton (1. c.) records, for the epidemic of 1782 in 
Britain, that in several garrison towns, such as St. Albans, 
Aberdeen, and Dublin, the military part of the population was 
attacked first, and suffei'ed most sevei'ely ; in Novara also, 
according to the communications of Galli (1. c), the disease, 
during the epidemic of 1833, showed itself first among the 
troops (in July), and not until a month later among the civil 
population; on the other hand, as Follet relates (1. c), the 
epidemic of 1838 at St. Denis (Eeunion), entirely spared the 
military garrisoning the place. Concerning the great 
epidemic of influenza which prevailed in upper India in 1832, 
Ludlow remarks :^ " At MhoAv it first attacked the natives 
in the Sudder Bazaar in considerable numbers ; ... it 
afterwards spread amongst the officers and servants. At a 
time when seventy or eighty men of the 65th Regiment were in 
hospital in consequence of the epidemic, not more than a case 
or two occurred in the 7th Cavalry, although both corps had 
lately arrived at the station.'^ To the same effect, Mouat^ 
reports from Bangalore : " Even here it had its anomalies, by 
affecting the Native Horse Artillery and entirely exempting 
the European Fort Artillery, who were about 100 strong." 
Regarding the epidemic at St. Petersburg in December, 1836, 
Seidlitz remarks •} " It did not attack the whole population 
of the capital at once^ as in the former epidemics (1831 and 
^^33)> ^^t it appeared now here, now there, in many of the 
streets and in many of the households several Aveeks later than 

> ' Calcutta Med. Trans.,' vi, 473. 

' lb., vii, 299. 

^ 'Ilufolaud's Journal der pract. Ileilkde.,' 1837, Ixxsv, 114. 


in tlie rest.^' In the report of Staberoh for tlie Paris 
epidemic of 1837, it is stated :^ '^ In this epidemic, just as in 
the sad time of the cholera, it was observed that particular 
parts of the city were spared without conceivable reason, 
while the neighbouring parts were severely attacked." In 
the Boston epidemic of 1825, according to the report of 
Dewees (1. c), only the children sickened at its commencement 
(December), and it was not until the middle of January that 
adults were seized; also in the Dublin epidemic of 1847, it 
appears, from the narrative of Churchill (1. c), to have been 
the children that suffered. In the epidemic of 1837 ^^ Rennes, 
the malady had become widely distributed through the 
population as early as February, but, according to Toulmouche 
(1. c), it was not until April that it appeared among the 
inmates of the central prison. 

§ 4. Geographical Disteibution. 

The geogrcqjMcal distribution of influenza extends, with- 
out doubt, over the whole inhabited globe. From some 
large tracts of country, such as the West Coast of Africa, 
and the southern part of South America, no records of 
inHuenza epidemics have reached us, and the records for 
some other countries, such as the Cape, India, Australia 
and Polynesia, are but scanty ; but this does not justify 
the conclusion that the disease has not been prevalent at all 
•or only rarely in these countries, any more than the silence 
■or the scattered notices of the chroniclers and physicians of 
the middle ages justify us in concluding that the disease 
was absent or of rare occurrence during that period. That 
influenza has been observed" in several of the regions named, 
and especially in tropical latitudes, just as often as in Europe 
and in North America, we learn not only from the records of 
influenza epidemics as given in the chronological table, but 
also from the published observations of Bennet,"Ellis,^ Wilkes,* 

' Casper's ' Wochenschr. f. cl. ges. Heilkde.,' 1S37, 266. 

2 ' Lond. Med, Gaz.,' ix, 631. 

^ 'Polynesian Eesearches,' 1836, iii, 35. 

* ' U. S. Exploring Expedition,' iii, g^. 


Hiiole/ and Giilick" for Australia and Polynesia^ of Don^ and 
Lord'^ for India, of Riifz" and Carpentin^ for the Antilles, as 
well of various authorities for Reunion and Mauritius. The 
predominance of the disease in temperate latitudes, it is quite 
obvious, is only an apparent one. The alleged cnclemicity of 
influenza also, in several countries situated within the cold 
zone, reduces itself, accoi'ding to the data of Schleisner'^ 
Hjalteliu, and Finsen for Iceland, of Panum ^ for the Faroe 
Islands, and of Lange for Greenland, to the question whether 
influenza may not have been confused with the bronchial 
catarrhs that occur every year in wide distribution in these 
countries in spring and autumn, influenza itself being not 
really more frequent than in other latitudes. In Iceland, as 
Hjaltelin remarks^ it appears at a time when it is prevalent 
elsewhere, either in Northern Europe, or in North America. 

§ 5. Relation to Seasons and Weather. 

Independent, therefore, of climate, as influenza appears to 
be in its geographical distribution, it is equally little influenced 
in its occurrence by telluric conditions. It has prevailed with, 
as great intensity and in as great extent on marshy as upon 
dry soils, on impervious as upon porous soils, in valleys as 
on plateaus or in the hills, on the coast as in the interior, 
giving evidence, therein, of an ubiquity which belongs to no 
other of the acute infective diseases. 

But influenza shows the same independence, as regards 
its origin, of the seasons and of the influences of the 
weather; and it is in that respect that it is marked off 
most essentially and most decidedly from epidemic bronchial 

Respecting the prevalence of influenza epidemics in par- 

' 'Sandwich Island Notes,' Lond., 1S54. 

- L. c. ad ann. 184S. 

^ ' BomLay Mod. Trans.,' iii, 10. 

■« ' Quart. Journ. of Cal. Med. ISoc.,' i, 462. 

^ L. c, ad ann. 1850-51. 

^ ' Archiv de uied navale,' 1873, xx, 433. 

" ' Island undersogt for et laegvidenskabel Synspunlit.' Kjobeuh. 1849, 41. 

^ ' Bibl. for Laeger,' 1847, i, 311. 


ticular seasons, it is shown bj the table of outbreaks given 
above, tliat of 125 epidemics or pandemics which ran their 
course independent of one another, fifty began in winter 
(December to February), thirty-five in spring (March to May), 
sixteen in summer (June to August), twenty-four in autumn 
(September to November). Certainly winter comes out very 
decidedly as the season of the year most favorable to the setting 
up of the disease ; but wc shall attach very limited importance 
to that as a factor in the pathogenesis when we call to mind, 
that an epidemic once developed runs its course equally through 
all seasons of the year, of which fact the pandemics of 1580, 
1781-82, 1831, 1832-33, 1836-37, are striking illustrations. The 
disease in Greenland exhibits the same behaviour in its pro- 
gress ; in that country it makes its appearance in the north 
during the winter, and it does not reach South Greenland 
usually before the summer (Lange). It is also noteworthy 
that the influenza season in several tropical regions — for ex- 
ample, the Indus valley (Lord), and the Antilles (Rufz) — 
is the hot season ; of twenty-four epidemics of influenza 
observed in tropical latitudes, nine began in the hot season, 
seven in the cold, and seven in the transition period. 

•Just as influenza has prevailed in all seasons of the year, it 
has also occurred under the most various conditions of the 
weather — high and low temperature, steady and changeable 
weather, much or little atmospheric moisture. The disease 
has been very frequent in summer with a very high thermo- 
meter and great dryness of the air : for example, in 
Sv.'itzerland in 1557,'^ in the Rhine provinces and in Italy in 
1580," in the New England States in 1655,^ at Augsburg in 
1 712, Nismes, Lille, Gusset and other places in France in 
1762,* in Paris,^ Northern Italy,^ and Gibraltar^ in 1782, at 
Plymouth and London in 1788, in the Antilles in 1823, in 

^ Gesner's explanation is (1. c.) : — " I see no other cause tlian the southern 
character of almost the whole summer." 

- Thomasius observes (1. c.) : — " A certain accession became apparent in 
the hot weather." 

•* Webster, 1. c. 

* Eazoux, Bouchet, Desbrest, 1. c. 

'" Geoifroy, 1. c. 

'' Rosa, 1. c. 

" Maclean (1. c. 291), speaking of the epidemic of influenza, adds the 


China and at Manilla in 1S30, at Stuttgart, Heidelberg, and 
in the Duchy of Nassau in 1831 and 1833. On the other hand, 
epidemics of influenza have been repeatedly observed during 
the cold weather of a severe and protracted winter : for 
example, in Northern Italy in 1709 and 17 12, at Padua (" tem- 
pestate frigida et sicca, coelo die noctuque sereno,'^ Morgagni, 
1. c), in 1733 at Dijon and at York (where the epidemic broke 
out in the end of January during intense cold, the weather 
to the middle of the mo:ith having been moist and mild) in 
many parts of Germany dui'ing the very severe winter of 1 742 
(Juch), in the year 1775 in Clausenthal (where the disease 
appeared when a period of relaxing weather gave way to in- 
tense cold) in Reval and other parts of Russia in 1782, in 1827 
in Siberia and the eastern parts of European Russia (where the 
sickness which had prevailed during severe cold disappeared 
on the setting in of moist and changeable weather), at Riga in 
1832, inWiirtemberg in 1837, at St. Petersburg and inSchles- 
wig-Holstein in 1847, ^^^ ^^ Central Franconia in 1857-58. 
That the prevalence of weather characterised by much atmos- 
pheric moisture and by heavy rains does not prevent epi- 
demics of influenza from breaking out, is proved by the obser- 
vations made in London in 1658, at Pressburg in 1675, at Yoi'k 
in 1729, in the Netherlands, at Plymouth, and in Italy in 
1732, in Yorkshire and at Boulogne in 1757, at Heidelberg 
in 1780, and to come to more recent times, at St. Petersburg 
in 1854-55. There is not the slightest ground for assuming 
a causal connexion between the production of influenza and 
certain states of the barometer. Just as little do later in- 
quiries bear out the conjecture of Schonbein, and the state- 
ments of Spongier, Bockel, Jung, Granara, and others, that 
ozone has an influence on the development of epidemics of 
catarrh and influenza. As for the relation between sudden 
mists and the epidemics of influenza that have followed close 
upon them, some investigators have dwelt upon that sequence, 
but the theories of pathogenesis deduced therefrom may be 
relegated to that domain of fancies which the romancists 
of the profession have established in the province of etiology. 

Tvovds : — " Whicli was attributed at that time to the extraordinary heat o£ 
the atmosphere." 


§ 6. Special Liability op Natives and Exemption op 


Conditions of race are entirely without significance for tlie 
distribution o£ influenza. This is proved by observations 
made among mixed populations, by Cliisholm, Rufz, Carpentin^, 
and others for the Antilles, by Mouat for India, and by the 
chronicler of the epidemic of 1838 in Sydney. On the other 
hand, there have been noticed in various parts of the globe, 
certain remarkable differences between the indigeno^Ls and the 
foreign residents in their liability to influenza. The first in- 
formation on that point occurs in Barclay's report on the epi- 
demic of 1823 in the island of St. Thomas ; " the most remark- 
able thing about this disease," says the report, " was that new 
arrivals almost without exception were exempted from it, while 
it was so generally distributed among acclimatised persons and 
natives that very few of them escaped. While the hospital 
was crowded with old and acclimatised soldiers, there was 
not a single case among the recruits who arrived in the- 
beginning of the year (or six months after the outbreak of the 
epidemic). And the same circumstance was observed among 
the civil population ; the disease prevailed most widely and 
most acutely among the coloured people, many of whom died, 
while not a single case of death happened, to my knowledge, 
among the whites.'" Still more markedly has this peculiarity 
in the incidence of the disease shown itself in Iceland and 
the Faroe Islands. " The influenza," says Schleisner (1. c. 43),. 
" usually attacks the whole population (of Iceland), so that 
only a few persons escape it ; but it is the rule for this dis- 
ease, as it is for hydatids of the liver, to spare the Danes 
and other strangers. The medical officer for the district of 
"Westerland reports that, in the epidemic of 1843, not one 
man fell ill on board the vessels manned by Danes, while in 
the craft manned by crews of Icelanders, not a single person 
escaped ; and he adds that the same fact had been observed in 
the case of the Dutch and French fishermen in the epidemic of 
1834." Regenburg^ maintains that this assertion is unfounded; 
but Panum (1. c.) thinks his contradiction unjustified, all the 
' ' Sundhedscoll. Forhandl. for Aaret 1848/ 13. 


more so as the same observation — that natives and acclimatised 
persons alone sicken while strangers are spared — has been re- 
peatedly made in the Faroe Islands. The earlier observations 
have also been confirmed by the experiences in the epidemic 
of 1856 : " very few of the natives remained exempt from the 
disease while no cases occurred, neither on this nor on former 
occasions, among the strangers and recent arrivals/' says the 
above cited annual report. They are also borne out by the 
observations of Finsen^ for the epidemics of 1862 and 1864 ; 
and Lange records the same fact for Greenland.^ 

The behaviour of influenza in the same part of the 
world, affords evidence of still another peculiarity, viz. that 
the disease is most apt to break out on the arrival of ships 
from foreign ports. One of the earliest recorded facts of 
the kind comes from the island of St. Kilda (Hebrides).^ 
Panum, with reference to the same point in the Faroe 
Islands,'* says : " It is a remarkable fact that the outbreak 
of these (influenza) epidemics stands in near connexion 
■with the arrival of trading vessels, especially in the spring of 
the year; this circumstance cannot be regarded as merely 
accidental, inasmuch as the arrival of the first trader happens 
at various times, sometimes in March, sometimes in April, and 
sometimes not until May. "We know besides, from the obser- 
vations made by the government official Ployem, during the 
seventeen years that he spent upon the island, that the 
epidemic broke out each time two or three days after the 
arrival of the ship, that the first cases of sickness were those 
of the factors of the cargo and the men in their employ, and 
that the disease afterwards spread over all Thoi'shaveu and 
thence over the Avhole island." Finsen mentions the same 
fact for Iceland.^ That there is something more than acci- 

' L. c, 27. " De, som iiylig ere komme fra Udlandet og som altgaa ikke 
eve akklimatiserede, synes kun undtagelsesvis at vaere modtagelige for denne 

- L. c., 12. "Den europaiske Befolkning angribes i det Hele mindre 
liyppigt og mindre heftigt af denne Sygdom end de Indfodte ; men Euro- 
T)aevnes Modtageligbed for den tynes at stige, so langere de have opholt sig 
der i Landet, saa at Akklimatisernigen licr virker paa en modsat Maade af, 
hvad der er Tilfaeldet ved de saedvanligc Klimatsygdomme." 

3 Gray, in 'Lond. Med. Communications,' 1724, i, i. 

•1 'Bibl. for Laeger,' 1847, h 3'2. 

* L.c, p. 27. 


dent in tliis^ is proved' oy similar observations from other 
parts of the globe. Thus, in the Society Islands, accord- 
insr to the corroborative statements of Beunet and Ellis, 
influenza appears every time that a foreign ship arrives. 
For the Nicobars, Steen-Bille^ mentions the outbreak of an 
influenza epidemic immediately on the arrival of the Danish 
corvette under his command ; and Turner^ states that the 
disease prevailed for the first time in the Navigator Islands 
in the year 1830, directly after the arrival of the ship which 
brought the missionaries. The fact itself can hardly be 
doubted ; while the striking thing appears to me to be that 
the strangers themselves, in all the cases, have remained 
exempt or almost exempt from the epidemic. 

§ 7. Influence of the Weather in the Causation. 

The relations of influenza, so far as we know them, to 
climatic and telluric influences and to influences of the 
weather, do not help us much to explain the cause and origin 
of the malady, unless indeed we are content with conjectures 
that have no foundation and hypotheses for which there is 
no proof. The fact which has impressed the larger 
number of observers is that influenza has broken out and 
spread most frequently in the cold and moist weather which 
is especially apt to give rise to catarrhal sickness. On this 
observation has been based the assumption of an '^ evolution 
of influenza from bronchial catarrh,^"* the disease being nothing 
else than a '^ catarrh of heightened potency prevailing as an 
epidemic.^' But observant and unprejudiced investigators 
have at no time failed to remark how groundless this theory 
is, and how independent influenza is of the state of the 

Thus, so early a writer as Salius Diversus'^ has pointed out 
with reference to the epidemic of 1580, that its origin could 
not be referred to any appreciable changes in the atmosphere, 

1 ' Bericht iiber die Eeise der Corvette Galatea,' Kopeuh, 1852, i, 244. 

2 L. c, ad ann. 1830. 

^ ' De febre pestilente tractatus,' Francof, 1586, 62. 


inasmuch as the epidemic had occurred in various parts of 
Europe under different conditions of weather and at all seasons 
of the year ; the cause of the disease, he thought, was to be 
conceived of rather as a " trausmutatio in propria aeris sub- 
stantia," and as a " levis corruptio." By the same kind of 
reasoning, Molineux arrived at a similar conclusion for the epi- 
demic of 1693, which he was constrained to refer to something 
" subtle and occult " in the air. To the same effect are the 
statements of Whytt for the Edinburgh epidemic of 1757, of 
Baker^ for the influenza in London in 1762, and of Fothergill 
for the disease in Northampton in 1775. Peuada remarks 
that, in the epidemic in northern Italy in 1788, the sickness 
altogether spared the mountainous districts of the country, 
in which the influence of unfavourable weather must have 
been greatest and most persistent. Eespecting the epidemic 
of 1800, Metzer^ declares that he is obliged to dismiss all 
idea of a connexion between the origin of the disease and 
effects of the weather; and the same conclusion was arrived 
at by Barclay for St. Thomas in the Antilles (1823), by 
Ward for Penaug (1831), by Lombard for the Geneva epi- 
demic of the same year, by Berndt and Dieterich for the 
epidemic of 1833, by Greenhow and Graves for England and 
Ireland in 1837, and by others. Franque's resume of the 
records of influenza epidemics during the years 1 831 -1855 is : 
" The manner of spreading, as well as the essential chai-acter 
of the disease, was the same in all these epidemics, whether 
they reached their height in the winter, spring, or summer 
months." Kollmann draws attention to the fact that in Java, 
in the year 1831, the disease attained the same distribution 
on the coasts exposed to the tropical heat, and in the moun- 
tainous parts of the interior subject to cold and wet or 

* L. c, 8. "Enimvcro si morbus, de quo in praesentia agitur, iis coeli 
proprietatibus, quae sonsibus nostris se offerunt, ortum suum debuerit, qui, 
quaeso, factum est, ut non liomines, loco proximi, eodem fere tempore aegro- 
taverint? Qui factum, ut morbus eos, quos millia non amplius II ab hac 
urbe disjungunt, serior longe, quam Londinenses ipsos corripuerit .^ Quid- 
nam esse causae putomus, cur urbem Edinburgum ineunte Maio, aliquas 
vicina) Cambriaj partes recedente tandem Junionec prius invaserit? Profecto 
quidquid nobis de liac omni quaestione scire conceditur, angusta"admodum 
uietitur circumscriptio." 

' L. c, 4. 


variable weather. Finsen's conclusion^ from his observations 
made in Iceland,^ is that " states of the weather have no 
effect upon the origin of the infective disease in question, 
although they may affect its intensity/^ Some naval surgeons 
have thought themselves justified in referring the breaking 
out of the disease on board ship, especially on the high seas, 
to the effects of moist and cold weather on the crews ; but the 
small reliance to be placed on this opinion is apparent from 
the observations of medical officers of the English navy during 
the prevalence of influenza in i860 on board the ships of war 
cruising on the Australian station. " Where it originated," 
says the report," " there is no means of ascertaining ; it was 
generally ascribed to the state of the weather, but the influence 
of the weather as an exciting agent may be doubted, for the 
sickness seems to have been prevalent in all kinds of weather, 
whether cold or hot, wet or dry ; it also attacked different 
ships' companies at different times, though the vessels lay 
close to one another." Another interesting contribution 
towards the same opinion occurs iu the report, above men- 
tioned, of Chaumeziere, upon an outbreak of influenza on 
board a ship of war on a voyage from the "VYest Coast of 
Africa to Brest : " The epidemic came upon us," we read,^ 
" in the midst of the most favorable conditions for navig-atins", 
and with the temperature and other meteorological pheno- 
mena of a genial kind ; it showed itself, as has so often 
happened, under the influence of a general cause, specific, but 
unknown in its essential nature, and independent of all 
appreciable climatic or meteorological conditions." 

I have tliought it necessary to discuss the foregoing ques- 
tion somewhat fully, inasmuch as even at the present day 
there are still many voices raised, and influential voices too, 
against the specific character of influenza, and in favour of 
its identity, both in etiology and iu pathology, with epidemic 
bronchial catarrh.'^ I cannot conclude this section more 
suitably, perhaps, than by adducing the opinion arrived at by 

1 L. c, 26. 

2 ' Keports of the Navy for 1S60,' p. iSi. 

3 L. c, 37, 40. 

■* Thus, among others, Brochin in 'Diet. Encyclop. des sc. Med.,' 1872, 
xiii, Art. " Catarrh.," p. 242. 



tlie Wiirtcmberg physicians in the course of an investigation 
into the influenza epidemics of that kingdom in the years 
183 1- 1858: '^ It appears from these researches/' runs the 
report/ " that influenza prevailed sometimes in summer, 
sometimes in winter ; sometimes in unusually warm weather, 
and sometimes in unusually cold ; sometimes in dry weather, 
sometimes in wet. Considering, further, that the weather had 
thousands of times shown the same character as in influenza 
years, Avithout influenza prevailing, and that influenza is 
usually prevalent at one and the same time over the whole of 
Europe and even in other parts of the world, where we may 
safely conclude that the weather had been of all kinds, we are 
constrained to admit that influenza is altogether indeiJendent 
of weather conditions. Should we desire, however, to open up 
the further question of an influence exerted by agencies or 
substances such as the electricity of the air, ozone and the 
like, we should be well advised to wait for further observa- 
tions before taking the trouble to discuss it." 

§ 8. A Specific Infection. 

Influenza is a specific infective disease like cholera, typhoid, 
smallpox, and others, and it has at all times and in all places 
borne a stamp of uniformity in its configuration and in its 
course such as almost no other infective disease has. Its 
genesis presupposes, therefore, a uniform and specific cause, 
the origin and nature of which are still completely shrouded 
in obscurity. There can be no objection to calling this 
specific cause by the name of " miasma,'' so long as we 
remember that nothing more is expressed thereby than that 
which the physicians of the sixteenth and seventeenth 
centuries called a " fouling of the air," and that, in setting 
up a name in the place of an obscure conception, we do not 
bring ourselves by that means a single step nearer to a 
knowledge of the cause of the disease. All the opinions 
that have been put forward as to the nature of this " influenza 
miasma " are without any basis of fact ; and that is true more 
especially of the theory, maintained as early as the eighteenth 
^ 'Wiirtlcmb. med. Correspondenzbl.,' 1858, 188. 


century/ and lately revived, of a " miasma vivum/^ or an 
organic (animal or vegetable) morbid poison, upon the carry- 
ing of wliicli by the air the spread of the disease was thought to 
depend. But, as Ave have already seen, there is not the slightest 
cogent reason for supposing that the several parts of an in- 
fluenza pandemic stand in a genetic relation to one another, or 
that it is a question of the conveyance of a disease-producing 
substance from place to place. We might with just as much 
probability assume that the cause of the disease has sprung 
up de novo at all places where its effects have been mani- 
fested, as that it has been distributed by the movement of 
the air. And, indeed, the circumstance that the progress of 
the disease does not depend on the direction of the Avind, and 
may sometimes even go contrary to it, speaks in favour of 
the former view. Thus the epidemic in England in 1803 
extended from south to north during the prevalence of north- 
easterly winds ; and the report on the influenza epidemic of 
1831-37 in Denmark says :^ '^ Another interesting question 
is whether the disease went in a westerly direction with 
an easterly wind ; Dr. Bremer, on comparing the direction of 
the wind for each day, came to the conclusion that there was 
not the smallest connexion discoverable between it and the 
spread of the epidemic, and that the course of the latter was 
wholly independent of the wind.'' In 1834, according to 
the account of Schleisner,^ the influenza in Iceland went 
from north to south during a prolonged tract of westerly 
winds ; and Finsen,* with reference to the distribution of the 
disease in general in that country, says : " An epidemic 
will spread over the whole island quite independent of wind 
and weather. '^ 

^ " This disease," says Grant, in his account of the influenza epidemic of 
the year 1782, "is prevailing in certain districts of France at the moment of 
my present writing. It is there called ' la gripe,' from an insect of that 
name, which was very common in England and France during the past 
spring, and was supposed to have infected the air and imparted an injurious 
property .to it. We know, however, that this view rests upon an error." 
According to Metzger (' Zur Geschichte der FriihlingsepiJemie, &c.,' 
Konigsh., 17S2, note 5) a similar conjecture was made by Kant, that "the 
Eussian trade with China had brought over some species of noxious insects, 
which might have got scattered abroad in course of time." 

2 'Bibl. for Laeger,' 1847, July 6th. 

» L. c. 44. ^ L. c, 26. 


§ 9. Alleged Contagiousness. 

The question whether influenza is communicahle or con-- 
tagious has given occasion to a lively controversy. In more 
recent times the great majority of observers have answered 
it decidedly in tlie negative, not so much on the strength of 
the many single observations which tell against the com- 
municability of the disease, as on the ground that the spread 
of influenza can be shown to have taken place quite inde- 
pendently of intercourse. To this argument I may add the- 
fact that it has not spread more quickly in our own times, 
with their multiplied and perfected ways and means of com- 
munication, than in former decades or centuries. " The- 
simple fact is to be recollected,'^ says Jones,'^ " that this 
epidemic affects a whole region in the space of a week, nay, 
a whole continent as large as North America, together with 
all the West Indies, in the course of a few weeks, while the- 
inhabitants could not within so short a time have had any 
communication or intercourse whatever across such a vast 
extent of country. This fact alone is sufficient to put 
all idea of its being propagated by contagion from one 
individual to another out of the question.'^ The Provincial 
Medical Association in England gave special attention 
to the question of the contagiousness of influenza in the- 
epidemic of 1836-37 ; the result of their observations thereon 
is summed up by Streeten in the following words :" — " The 
answers to this question — ^Are you in possession of any 
proof of its having been communicated from one person to 
another ' — are of an almost uniform tenour, the opinion of ' 
nearly all those w^ho had the most extensive opportunities of 
investigating the disease, and the best means of arriving at 
a definite conclusion, being that there is no proof of the- 
existence of any contagious principle by which it was 
propagated from one individual to another." 

Partisans for the spread of influenza by contagion have 
found support for their views in the breaking out of the 
disease at various places, somewhat removed from the track 

1 'Philadelphia Journ. of Med. and Phys. So.,' 1826, n. s., iv, 5. 

2 ' Trans, of the Prov. Med. and Surg. Assoc.,' 1S38, vol. vi, pt. ii, 523. 


"df commerce^ afuer the an*ival of strangers ; for example, tlie 
Dc'iuish physicians in Iceland and the Faroe Islands have 
found evidence of that kind in the outbreaks of influenza 
that have followed the arrival of foreign ships. Without 
questioning the accuracy of the observation itself, we may 
hesitate to accept the conclusious di^awn from it when wo 
duly keep in mind that the suspected importers of the 
morbid poison remain, as we are expressly told, unaffected 
by it, that they continue untouched by the epidemic, and, 
further, that the disease has not unfrequently appeared in 
these and other islands at the time of the ship's arrival 
although influenza had not been prevailing as an epidemic 
anywhere else, and most certainly not in those countries 
from which the ships had sailed. These considerations, 
taken along with peculiarities in the incidence and course 
of influenza epidemics — their occurrence suddenly and with- 
out prelude, and their attacking the people en masse, 
their equally sudden and complete extinction after a brief 
existence, generally of two to four weeks, and the frequent 
restriction of the disease to one place, while the whole 
country round has been completely free from it — all these 
points are so foreign to the mode of development and the 
mode of spreading pi-oper to such maladies as originate 
beyond doubt through the communication of a morbid poison, 
that we shall find it hard to discover any reason for counting 
influenza among the contagious or communicable diseases. 

§ 10. Unifoemity op Type. 

Few among the acute infective diseases have manifested, 
in their prevalence at all times and in all places, the stamp 
of uniformity so strongly in the aggregate of symptoms as 
influenza. The various epidemics, it is true, have differed 
•much among themselves as regarded the character and 
course of the disease, but these differences — expressing 
themselves in a catarrhal affection particularly of the diges- 
five mucous membrane, in the occurrence of exanthems, in the 
remarkably frequent accession of more severe inflammatory 
affections of the respiratory organs — have been found to be 


associated either witla a particular season of the year or kind 
of weather^ or Avith something special in the locality, and 
have been not unfrequently determined more by the indivi- 
duality of the sick person than by anything in the external 

§ n. Coincident Outbreaks op Influenza among Horses. 

I do not think that I need now enter at length upon a 
subject that was so keenly discussed some forty years ago_, viz. 
the relation of influenza epidemics to the epidemic prevalence 
of other infective diseases, especially the cholera. That 
influenza should have preceded the outbreak of cholera in 
1 83 1, will be seen by a reference to the history of each of 
those diseases to have been accidental. If we may not speak 
of " accident " in the course of natural events, then, as Glnge 
justly remarks, we are at least debarred from, calling it by 
any other name. 

But I am not of opinion that there is any question of acci- 
dent inthe relation ofirflnenza epidemics to epizootics of the same 
character prevailing at the same time, especially among horses, 
and, next to them, among dogs, cats, and the like. Even 
in the oldest epidemiological records, there are indications 
of these coincidences both as regards time and place, as 
well as of the identity or at least similarity of the form of 
disease ; and the number of these observations is so remark- 
ably large that the suggestion of an etiological and perhaps 
also pathological connexion between the epidemics, on the 
one hand, and those epizootics, on the other, may be 
regarded as provisionally proved, although it ought not at 
the same time to be left out of sight that the notion of 
"horse-influenza^' has remained to the present day a some- 
what vague one with veterinary surgeons, and that very 
various diseased processes appear to have been included 

The first communication relating to this matter which has 
any value occurs in the account by Molineux of the epidemic 
of 1693. "It was remarkable," says that writer, "that 
both in England and in Dublin shortly before the outbreak 


of tliG influenza, there was a disease prevalent among the 
horses, not of a severe type but very general, which manifested 
itself chiefly in a discharge from the nostrils of the animals.'" 
To the same purport is the statement of Gibson^ about an 
epizootic among horses which was rife in England and 
Scotland during the autumn and winter of 1732-33 at the 
time of the prevalence of influenza, and upon which Huxham 
also comments." ''About the end of the year 1732/^ says 
Gibson, " there was a very remarkable distemper among the 
horses in London and in several other parts of the kingdom. 
They were seized suddenly with a vehement, dry-sounding 
cough, which shook them so violently that some of them 
were often ready to drop down with hard straining and want 
of breath ; their throats were raw and sore ; . . . the 
running at the nose generally began the third day and 
continued in so profuse a manner for five or six days that 
some of them in that time discharged as much as two or 
three pails would hold of purulent matter, which, however, 
was generally of a laudable colour and good consistence. 

. " This distemper, though in no ivays mortal, yet was so 
very catching that when any horse was seized with it I 
observed those that stood on each hand of him were 
generally infected as soon as he began to run at the nose, 
in the same manner as the smallpox communicates the infec- 
tion when they are upon the turn.''^ From the spring of the 
year 1767, in which influenza prevailed widely over Europe 
and North America, we have similar observations on the 
simultaneous occurrence of an epizootic in those countries 
among dogs and horses. " When I was in England in the 
year 1767,^^ says Mumsen,^ "we had cold north-easterly 
winds till late in May, following a severe winter. A 
pestilence broke out among the dogs and horses, 

it was called ' the horse cold ' (Pferde-schnupfen) ; it 
occurred also among men, but it had no sei-ious conse- 

'' 'Diseases of Horses.' Quoted by Heusinger, 'Eecli. de 
paree,' vol. ii, p. 220. 

' ' Observat. de aere et morb. epidem. &c.,' Lond., 1752, 73 — 75. 

2 In a tract published anonymously, ' Kurze Nacbricht von der Epid. 
Schnupfen-Krankheit, n. s. w.,' Hamburg, 1782, 20. There is another 
account of this epizootic in the ' Hannov. Magazin,' 1767, p. 1645. 


qucuces." Webster,^ the American autliority, mentions an 
epizootic during the same period among the horses in New 
England and New Jersey. In his account of the in- 
fluenza epidemic of 1775 in England, Fothergill refers to the 
simultaneous occurrence of the disease among dogs and 
horses : — " The horses/^ he sajs^ " had severe coughs, were 
hot, forbore eating, and were long in recov^ering ;'' and Parr 
adverts to the same fact in the English epidemic of 1782. 
Simmons^ adduces the following obsei'vation communicated 
to him by Surgeon Boys, of the navy, for the epidemic of 
1788 : — '' On the arrival of the Frigate ' Rose ' at Portsmouth 
from Newfoundland (on the 4th of November, at the time 
when epidemic influenza was prevalent), all the dogs on 
board the vessel were seized with cough and catarrh, and 
shortly thereafter the whole ship's company sickened in a 
similar manner/' During the influenza epidemic of 1837 
in Cassel, " a catarrhal condition," as the report has it,^ 
" showed itself among the horses/' At the time when the 
disease was prevalent at the Cape of Good Hope in 1853 and 
1854, the horses suffered from a similar malady, which 
destroyed many of them. In the report upon the influenza 
of 1857-58 in Wiirtemberg it is stated: ''"With reference 
to this point (influenza-like ailments among the domestic 
animals during the prevalence of influenza), the account by 
the Court Veterinary -Surgeon Worz contains facts of in- 
terest. After similar ailments had manifested themselves 
in April and May, the disease spread in the end of December, 
in epidemic form, to a portion of the royal stud, in which 
were chiefly young horses, four and a half to six years old, 
partly of pure Arab breed, partly of Arab crossed with 
English ; in a few days forty out of forty -four horses were 
seized, only four of the older horses escaping. Out of 100 
horses in the royal stables, only thirteen were attacked 
up to the 1 2th of January, and these also were the younger 
horses, the severest case being in a thoroughbred Arab 
stallion. Thus only young horses, and of good strain, fell 
ill. The symptoms were exactly those of influenza in man. 

' L. c, i, 256. 
.2 L. c, 266. 
^ Casper, ' Wocbensclir./ 1837, 231. 


All tlie auimals recovered/' To conclude this 
summary of epizootics coinciding in time and place with 
epidemics of influenza, and probably to be accounted true 
cases of animal influenza,, I shall advert further to the great 
horse plague which overran the North American continent 
as a pandemic in the years 1872 and 1873, at a time 
when influenza was rife over the whole of that continent. 
Hertwig^ gives the following account of it from the reports 
of veterinary sui-geons in America : — " The animals sickened 
always suddenly, with extreme weakness, coldness of the 
extremities, loss of appetite, redness of the conjunctiva, dry 
cough, and quick pulse. The respiration was impeded, the eyes 
ran, and there was a serous discharge from the nostrils, 
turning to a mucous consistence and a yellow colour about 
the third to the fifth day. Between the seventh and tenth 
days the cough became looser, the animals became more lively 
and inclined for their food, the pulse fell, and after ten to 
twelve days they were mostly well. In a few cases, 
which ran an especially rapid course, sweating set in on the 
third or fourth day ; in other cases the illness was protracted 
over three weeks, and was followed by great prostration, and 
sometimes by general dropsy. The outbreak of the plague 
was sudden and general (as in the case of influenza), and 
the duration of it in the several localities averaged four to 
six weeks. On the whole, ninety per cent, of all the 
animals were attacked, and three to four per cent, of those 
attacked succumbed. The epidemic prevailed equally 
among horses of every age and race. At certain places, 
as, for example, Washington, the sickness was so widely 
.spread that not one horse escaped it." 


Gexeeal Mehoies. 

Saillant, Tabl. hist des epidemies catarrliales. Paris, 1780. Zeviani, in 
Mem. di mathem. e di fisica della soc. Ital. delle science, si, p. 476. Most, 
Influenza europaea. Hamb., 1820. Schweich, Die Influenza, etc. Berl., 
1836. Gluge, Die Influenza oder Grippe, etc. Minden, 1837. Tlieophilus 

^ ' Magazin fiir die gesammte Thierbeilkunde,' 1873, xxxix, 94. 


Tliompson, Annals of Influenza or Epidemic Catarrhal Fever in Great Britain 
from 1510 to 1S37. Loud., 1852 (Sydenham Society). 

Eefeeences in Chonological Oedee. 

1137- — I. Sigberti, Chron. in Pertz Annal., vi, p. 414, Annal. Blandin- 
iens., ib. v, p. 29. 2. Godefridi Annal. in Freheri rer. german., script, i, 
p. 341, Chron. Vetero-Cellense min., in Menckenii Script, rer. german, ii, p. 
438, Chron. Saxon., in Lcibnitzii Acces. hist., i, p. 310. 3. Radulfus de 
Dicetus, in Twysden, Script, hist, angl., p. 579. 

1323. — I. Buoninsegni, Hist. Fiorent. Firenze, 1581, p. 167, Villani 
Istor., L. ix, cap. 221. 

1328- — I. Buoninsegni, 1. c, p. 216. 

1387- — I- Buoninsegni, 1. c., 678, Minerbetti in Taiiini, Eer. ital. script, 
ii, 106, de Mussis in Muratori, xvi, p. 546. 2. Valescus de Tharanta, 
Pliilonium., lib. ii, cap. 60, De catarrho Prognosticatio. Lugd., 1490, fol. 
80 b. 3. Aunales Augstburg. in Menckennii Rer german, script, i, p. 1526. 

1404. — I. Mansfeld. Chron. Frcft., 1572, fol. 353 b. 2. Bali olani, Annal. 
rer. Flandric. Antw., 1559, fol. 220 a. 

1411, — I. Pasquier, Les recherches de la France. Par., 1661, fol. 375- 
"■ 1414- — I. De Griifon, Memor. hist. rer. Bonon, xviii, 222. 2. Chron. 
Foroliv. in Muratori, xix, 883. 3. Sanuto, Vite de' Duchi di Venezia, xxii, 
887. 4. Cambi, Istor. di Firenze in Deliz. degli erud. Tosc. xx, 138. 5. 
Sauval, Reoherch. des antiquites de la ville de Paris. Par., 1724, fol. 558. 

1427- — I- Pasquier, 1. c. 

1510. — I. Fernel, Deabditis rerumcausis. Frcft., 1607, 214. 2. Paraeus, 
Wundartzency. Frcft., 1635, 697. 3. Muralti, Annalia. Mediol., 1861, 
132. 4. Bouchet, Les Annales d'Aquitaine. .'Poitiers, 1644, 332. 5. 
Short, A General Chronological History of the Air, Weather, Seasons, etc. 
Lond., 1749. 

1557- — I- Ingrassia, Informazione del pestifero e contagioso morbo, etc., 
p. 60, 102. 2. Amatus Lusitanus, Curat, medicinal. Cent, vi, cur. 68. 

3. Fallopia in Fantuzzi, Vita di Aldrovandi, -p. 196. 4. Cavitelli, Annales. 
Crem. 1588, c. 341. 5. Gcsner, Epistol. med. Tiguri, 1577, lib. iii, c. 82 b. 
6. Valleriola, Locor. commun. Appendix, cap. 2. Lugd., 1589, 64. 7. 
Coyttarus, De febre purp. epidem. Par. 1578, p. 6. 8. Rondelet, Method, 
curand., etc. Frcft., 1592,700. 9. Eiverius, Observationes communicatae. 
Venet., 1723, 570. 10. Dodonaeus, Med. obs. exempla., cap. 21. Colon., 
155I' 52. II. Forest, Observ. et curat, med., lib. vi, obs. i, 2, 12. Mercatus, 
De corporis hum. afEect., lib. ii, caj). i, 0pp. Venet., 161 1, ii, 143. 

1562- — I. Augenius, De febribus, lib. ^^, cap. 3. 2. Ajello, Breve disc, 
intorno ai catarri, etc. Napoli, 1597, 9. 3- Cardano, De providentia ex 
anni constitutione in 0pp. v, 15. 

1580- — I. Heidenstein in Cromeri Chronicon. Colon., 1589, fol. 786. 
2. Wittich, Von den Eigenschaften , . des neuen epidemialischen, katar- 
rhalischen Fiebers, u. s. w. Leipz., 1592. 3. Sporisch v. Ottenbachau, 
Liber de febre epid. anni 1580. Cum ejd. Idea medici, etc. Frcft., 1582, 

4. Henisch, Aetiologica . . .ad modum et ductum Aretaei. Aug. Vind., 


i6oj, 396. 5. Pechlin, Obscrv. med. Hamb., 1 691, 244. 6. Covvadi in 
Annali univ. di Med., 1866. Vol. cxcvii and cxcviii, and Annali delle 
epidemie occorse in Italia, etc., parte ii, 274 (thorough and comprehensive 
account of the epidemic in Italy). 7. Chytraeus, Saxonia ab anno 1500 
usque ad ann. 1600. Lips., 161 1, £ol, 691. 8. Forest, 1. c. (ad ann. 1557). 
9. Thomasius, Tract, de peste. Romae, 1587, 101. 10. Mezeray, Hist, de 
la France. Paris, 1685, t. iii, fol. 496. 11. Coytard de Thaire, Discours de 
la coquelucheetautres malad. popul.etc. Poictiers, 1580. 12. Mercatus, 1. c. 
(ad ann. 1557)- I3- Summonte, Dell' historia della citta e regno di Napoli. 
Nap., 1643, iv, 419, 425. 13 a. Villalba, Epidemiologia espanola. Madr.j 
1802, i, 196. 14. Stengel, natura, causiset curatione morbi cpid., 
anni 1580. Aug. Vindel., 15S0. 15. Wier, Obscrv. med., lib. ii, 0pp. 
Amstelod., 1660, 978. 16. Bokel, Synops. novi morbi, etc. Helmst., 1520. 
17. Meister in Script, rer. Lusaticor., i, Pars ii, 42. 18. Karpzow, Annal. 
Zittav., etc. Zitt., 1776, 307. 19. Chronik von Leisnigk. Leisn., I7.'^3, 
433. 20. Lindenbrog Chron. Rostoeh., iv, cap. 12, 136, 

1591. — I. Wittich, 1. c. (ad ann. 1580 in the preface). 2. Sennert, Pract. 
med., lib. i, j^art. ii, cap. xxxiv. Wittbg., 1654, i, 705. 

1593. — I. Cagnati, De Tiberis inundatione med. disp., etc. Rom., 1599. 
21. 2. Du Laurens, Oeuvres. Par., 1686, 321. 

1597- — I- Corradi, Annali delle epidemie, etc. Part, ii, 331 (based on 
accounts from Bologna, Venice, and Verona). 

1626- — I. Doni, De restituenda salubritate agri Romani, in Sallengre, 
Nov. Thesaur. antiquit. Roman., i, 916. 2. Pascal, Rec. de mem. de med. 
milit. 1851, Ii, 68. 

1647- — I. Villalba, Epidemiol, espanola, ii, 72. 2. Morejon, Hist. bibl. 
med. espagn.,iv, 64. 3. Thacher, Amer. Med. Biography. Bost., 1828. 4. 
Webster, History of Epid. Diseases, etc. Hartford, 1799, i, iSS. 

1655- — I. Webster, 1. c. (ad ann. 1647), i, 189. 

1658. — -I. Bindi, Laemografiae Centumcellensis. Romae, 1658, 78. 2. 
Timaeus v. Giildenklee, Epistol. et consil. Epist. xiv, 0pp. Lips., 1715, 
413. 3. Willis, Diatr. de febribus, cap. xvii, 0pp. Amstelod., 1682, 143. 

1675. — I. Ettmiiller, Colleg. consult, cas. vii, 0pp. Lugd., 1685, iii, 150- 

2. Marechal, Tableau des malad. endemiques et epidem. de Metz, etc. Metz, 
1850, 197 (see also Peu, La pratique des accouchemens. Paris, 1694, 59). 

3. De Sorbait, 0pp. med. Vienn., 16S0, 92. 4. Rayger in Miscell. Acad., 

Leopold, Dec. i, Annal., 1677, 213. 5. Sydenham, Const, epid. v, cap. i, 

0pp. Genev., 1736, i, 135. 

1 RSfi "^ 

■ > — 1. Molineux, in Philos. Transact. Lond., 1695, xviii, 105 fE. 

1709. — I. Lancisi, De advent, coel. rom. qualitat., etc. 0pp. Genev., 
1718, 126, 2. Corradi, Annali delle epid. Part, iv, 20, 21. 3. Hoffmann, 
Med. rational, syst. iv, part, i, 0pp., 135. 4. Ilmoni, Bidrag til Nordens 
sjukd. histor., ii, 329. 

1712- — I. Botticher, Pestis et pestilentiae explicatio. Hamb., 17 13, 43. 
2. Waldschmidt, De Singular, quibusd. pest. Holsatiae, Kil., 1721. 3. 
Slevogt, Prolusio, qua " die Galanteriekrankheit " delineatur. Jen., 1712. 4. 
Schrockh in Ephemer. Acad. Leopold. Cent, iii etiv, App. 26. 5. Camerer, 


ib., 1 7 15, 137. 6. Bianclii, Ilist. liepatica, Pars iii, Const, anni 17 12. 
Oenev., 1725, ii, 720. 

1729-1730- — I- Biichner, Miseell. med.-plij^s.-mathem. Anni 1729 et 
1730 passim. 2. Loew, Kuvze unci griindl. Untersuchung . . . des Catar- 
rhal-fiebers (s. 1.), 1730, and Hist.febr. catarrh, in Sydenham 0pp. Genev., 
^73^> ii) 344- 3- Pchu-gus, Observ. clin. Lips., 1735. 4. Hahn, Febr. 
contin. quae a., 1729, Vratislav. grassatae sunt recensio, etc. Vratisl., 1731. 
5. Jliihlpauer, Theses med de febre catarrhaL Noric, 1738. 6. Thompson, 
Annals of Influenza, etc. 7. Huxham (ad ann. 1732, 1733). 8. Wintring- 
ham. Comment, nosol. Berol., 1791, 117. 9. Scheuchzer, Act. Acad. 
Leopold, iv, App. 24. 10. Beccaria, ib. iii, obs. 48, 148. 11. Corradi, 
Annali delle epid., etc., partiv, 77. 12. HofEmann, 1. c. (ad ann. 1709), 338. 
13. Morejon, Hist. med. Espagn., vi, 351. 14. Hjaltelin, Edin. Med. Journ., 
1S63. Feb. 697. 

1732-1733. — I. Pelargus, 1. c. (ad ann. 1729), and in Commerc. litter. 
Norimb., 1733,52. 2. Albrecht, ib.'36. 3. De Gorter, Morbi epid. brevis 
descriptio, etc. Harderov., 1733. 4. v. Swieten, Epidemieen,etc. Leij^zig, 
1785, i, 402. 5. Stoch, Diss, de morbo epid., etc. Enchus., 1733. 6. 
Hoefferle, De febre catarrhal, epid., etc. Basil., 1733. 7. Marigne, Descript. 
d'une affect, catarrh, epid., etc. Montauban, 1766. 8. Jussieu, Quaestio 
med. an catarrh, epid. theriaca. Paris, 1733. 9. In Journ. gen de med., 
1733, xxi, 170. 10. In Edinb. Med. Inquiries and Observations, ii, 129. ir. 
Huxham, 0pp. Lips., 17S4, i, 102. 12. Arbuthnot, Essay concerning the 
Effects of Air on Human Bodies. London, 1751,193. 13. Wintringham, 
1. c. (ad ann. 1729, 30), 142. 14. Crivelli, Epidemic catarrali seguite negli 
anni 1730 e 1733 in Italia, etc. Milano, 1733. 15. Perkins in Hist de la 
Soc. roy. de Med. de Paris, i. Hist. 209. 16. Villalba, Epidemiol, espaiiola, 
11,189. ^7- Keamur in Hist, de I'Acad. des Scienc, 1733. Mem. 5S9. 18. 
"Webster, 1. c. (ad ann. 1647), i, 232. 19. Corradi, Aunali delle epidemic, 
etc., part, iv, 85. 

1735. — I. Hjaltelin,!. c. (ad ann. 1720). 

1737-1738.— I. Huxham, 1. c. (ad ann. 1732), i, 153. 2. Webster, 1. c. 
j(ad ann. 1647), i, 235. 3. In Journ. de Med., xxi, 453. 

1742.— I. In Commerc. litter. Norimb., 1743, 107, 188, 213. 2. Zuber- 
buhler, De febre catarrh, epid., etc. Erford., 1743. 

1742-43. — I. Corradi, Annali delle epidemic, etc., part iv, 112 (complete 
dist of Italian authorities on this ej^idemic). 2. Seelmatter, Morbi circa 
Tobinium familiares, etc. Basil, 1751. 3- v. Swieten, 1, c, ii, 435. 4. 
Pringle, Observ. on the Diseases of the Army, 4th ed., Lond., 1761. 5. 
Huxham, 1. c. (ad ann. 1732), i, 286. 6. In Journ. de Med., xxii,264. 

1757-1758.— I. Webster, 1. c, 246. 2. Hillary, Observ. on the Changes 
of the Air, &c., 2nd ed. Lond., i']66, 145. 3. Bisset, Essay on the Med. 
.Constit. of Great Britain, Lond., 1762, 180. 4. Whytt in Lond. Med. 
Observ. and Inquir., ii, 187. 5. Simson, ibid., 203. 6. Millar, ibid., 200. 
7. In Journ. de Med., ix, 185. 8. Boucher, ibid., 187. 9. Desmars, ibid., 
X, 361. 

1761-1762. — I. Webster, 1. c, i, 250. 2. Corradi, Annali delle epidemic, 
iv, 190. 3. Mertens in Observ. Med., ii, i. 4. Monro (Donald), Account 


of Diseases, etc., LoncL, 1764, 114. 5. Isenflamm, Vcrsucli von den Ursachon 
der gegenw. allg. Brustleiden, Wien. 1762. 6. Erdmann, Diss, de morbo 
catan-h, etc., Argent., 1762. 7. Razoux, Tabl. nosol. et moteorol., etc., 
Basle, 1767, 279. 8. Boucher in Journ. de mod., xvii, 2S6. 9. Desbrest, 
ibid., xxiii, 141. 10. Buker, De catarrho et dysenteria Londin, Lond., 1762, 
in Edj. Opuscul. med. Lond., 1771,5. 11. Watson in Philos. Transact.,. 
1762, vol. lii, 646. 12. Gillchrist in Edinb. New Inquiries and Obs., iii, 385. 
13. Eutty, Chronol. History of the Weather and Seasons, etc. 14. Gazette 
de France, 1762, July. 

1767. — I- Grimm, Sendschr. an Haller iiber die Epidemie zu Eisenach^ 
etc. Hildburgh. 176S, 108. 2. Abt, Diss, de febre catarrh, cpid., etc. 
Giess., 1767. 3. Vandermonde in Journ de Med., xxvii, 394. 4. Boucher, 
ibid., 396, 513. 5. Darluc, ibid., xxxi, 318. 6. Lepecq, Samml. von Beo- 
bacht. iiber epid. Kranlch., etc. (from the French). Altenburg, 1728,245. 
7. Heberden in Lond. Med. Transact., i, 437. 8. Pepe, II medico clinico, 
etc. Napol, 1768, 9. Villalba, 1. c, ii, 225. 10. Perkins, 1. c. (1732) p. 
211. II. Bajon, Nachrichten von Cayenne, ii, 62. 12. Targioni, Raccolta 
d'opusc. med., i. 

1772.— I. Webster, 1. c. i, 258, 259. 

1775-1776- — I. Lentin, Memorabilia annor., 1774 — 1777, p. 35. 2. 
Stoll, Eat. med. Vienn., 1777, i, 24. 3. Lorry in Hist, de la Soc. de Med., i, 
Mem. 5. 4. Lepecq, 1. c. (ad ann. 1767) 476. 5. Duperin in Jouni. de 
Med.,xlv, 412. 6. Bougnicourt, Diss, de affect, catarrh, epid., etc. Montpel., 
1776. 7. Grant (William), Observ., etc., Lond., 1782, 1S3. 8. Fothergillin 
Mem. of the Med. Soc. of London, iii, 30. 9. In Lond, Med. Observ. and 
Inquir., vi, 340, ff. 10. Martini in Targioni, Eaccolta,iv, 334. 11. Account 
after Fleury in Dubl. Quart. Joum., 1848, Febr. 

1780-1781- — I. Schonmezel, Anni med. Heidelberg, 1780 quadrienn. 
prim, exhib. Spec. Heidelb., 1780. 2. Coquereau in Hist, de la Soc. de 
Med. de Paris, iii, Mem. 16. 3. Geoffrey, ibid., iv, Mem. 2. 4. Porriguet 
in Journ. de Med., Ixxvii, 218. 5. Burseri, Instit. med. Lips., 1798, i, 413. 
6. Sigaud, Du climat et des malad. du Bresil. Par., 1844, 185. 7. Gili- 
bert, Adversar. med.-prac. Lugd., 1791, 97. 8. Webster, 1. c, i, 268. 

1782- — I- Languth, Diss. hist. Catarrh, epid. anni 1782 sistens. Helmst., 
1782. 2. Himly, Darstellung der Grippe, etc. Hannov., 1833. 3- Bluhm, 
Vers, einer Beschr. d. in Eeval herrsch. Krankh., 22. 4. Ilmoni, 
Bidrag, iii, 424. 5. In Wecko-Skrift for Lakare, etc., iii, 340, iv, 97, 
245. 6. In Baldinger, N. Magaz, v, 260. 7. Metzger, Beitr. z. Gesch. 
der Frilhlingsepidemie, etc. Konigsbg., 1782. 8. Lachmann, Diss. sist. 
obs. nonnull.pract. Eegiom., 1793. 9. Ivurze Nachricht v. d. epid. Schnup- 
fenkrankheit. Hamb., 1782. 10. Lentin, Beobacht. iiber die epidem. 
Krankheiten d. J. 1777-1782. Leipz., 1783, 8, and Beitr. z. Arzneiwis- 
sensch., i, 31. II. Thilenius, Med.-chirurg. Bemerk., ii, 117. 12. Acker- 
mann in Balding. N. Mag., iv, 3S5. 13. Planer in Act. acad. Mogunt., 
1782, 3. 14. Weikard in Med.-chir. Zeit., 1790, ii, 175. 15. Strack, Diss, 
de catarrh, epid. Mogunt., 1784. 16. Beschreib. der Epid. . . . im 
Friihjahre 1782, etc. Giessen, 1782. 17. Wittwer, Ueber die jiiugsten 
Catarrh. Xiirnb. 1782. 18. Schonmezel, Diss. sist. const, epid. Heidelberg^ 


anni 1781-17S2. Heidelb. 1782. 19. Andenverth, Diss. sLst. const, anni 
1782, etc. Friburg. Brist,'., 1782. 20. Bedenken der Prager Fakultiit iib. 
d. epid. Catarrh. Prag., 1782. 21. Thomas, Kurze Gesch. der neuen Epi- 
demie, etc. Nebst Fortsetzungen. Wien, 1782, 84. 22. Mertens, 1. c.,ii, 
33. 23. Benkoe, Ephemer. meteorol.-med., i. 67. 24. Raiioe in Act. reg. 
soc. ined. Ilavn. i, 351. 25. Tode in Nye Sundhedstidende, i, 106. 26. 
Michell in VaterL Letter-Oefeningen, iv, 389, and Geneesk. VerhandeL over 
de oorzaken V. d. febr. catarrh., etc. Middelb., 1785. Ger. transl., Coburg, 
1793. 27. Bronghton, Observ. upon the late Influenza, etc. Lond., 1782. 28. 
Clark, On the Influenza . . . at Newcastle, 1783. 29. Grant, Observat. 
on tlie late Influenza, etc. Lond., 1782. 30. Hamilton. A Descript. 
of the Influenza. Lond., 1782. 31. In Medic. Communicat. London, 
1784, i, 1 ff. 32. Fothergill in Lond. Med, Memoirs, iii. 33, Duncan, 
Diss, de catarrho, etc. Edinb., 1785. 34. In Edinb. Med. Comment., 
Dec. I, vol. X. 35. In Lond. Med. and Phys. J., x, 133. 36. Leroux 
in Journ. de Med., Iviii, 171, 267. 37. Geoffroy in la Soc. de Med. 
de Paris, v. 10. 38. Boucher in Journ. de Med., Iviii, 184, 278. 39. Rosa, 
De morbis epid. et contag. Moden., 1782. 40. Battini in Race, de opuscoli 
med.-pract.,vii,53. 41. Gallicio, Saggio soprailmorbo dettorusso. Venez., 
1782, 42. Asti, Memor. epist. intorno le malatt. occorse in Mantova, etc. 
Firenz., 1783. 43. Maclean, Results of an Investig. resp. Epid. and Pestil. 
Diseases. Lond., 1817, i, 291. 44. Con-adi, Annali delle epidemic, etc., iv, 

338, ff. 

1788.— I. Grill, Gesch, d. neuen epid. Flussfiebers, etc. Munch., 1788. 

2. Benkoe, 1. c. (1782), ii, 24. 3. Kletten in Wien. med. Monatschr., 1789, 
i, 33. 4. Falconer in Mem. of the Med. Soc. of Loudon, iii, 25. 5. Simmons 
in Med. Facts and Obs., 1788, 256. 6. Ibid., 274. 7. May in Edinb. 
Med. Comment., Dec. 2, vol. iv, 363. 8. In Gazette salutaire, 1788. 9. Dela- 
croix (in Ozanam, i. 190). 10. Boucher in Journ. de Med., Ixxvii, 288, 476. 
II, Tode in Museum for Sundhed, 1788, Juny, fE. 12. Penada, Delle osser- 
vaz. med.-pract. meteorol., etc. Padov., 1792. 13. Zeviani, 1. c. (general). 
14. Marc d'Espine, Gaz. Med. de Paris, 1848, Nr. 20 (after Odier). 

1789-1790.— I. Webster, 1. c., i, 288, 290. 2. Currie, Short Account of 
the Influenza, etc. Lond., 1790. Also in Transact, of the College of Physic, 
of Philad., i, P. I., 150. 3. Rush in Med. Inquir. and Observ., ii, 237. 4. 
Warren in Mem of the Med. Soc. of Lond., iv, 434. 5. Chisholm in Edinb. 
Med. Comment., Dec. 2, vol. v. 6. Lindsay, ibid., vii, 499. 

1798.— I. Webster, 1. c, i, 339. 

1799-1801. — I- Desbout in Giorn. per serviro alia hist, ragionata della 
med., xii, 233. 2. Metzger, Litteratur zur Geschichte der Friihlingsepide- 
mie im Jahre 1800. Altenburg, 1801. 3. Schlegel in Materialien fur 
Staatsarzneiwissenschaft. Sammlung 8. 4. Fischer in Hufeland J., xiii, 
Hft. 4, 29. 5. Winkler in Allg. mod. Annal., 1801. Corrsbl., 12. 6. Picker, 
ibid., 84. 7. Knebel,ibid., 1805. Corrsbl., 77. 8. Hopfengiirtner in Denk- 
schr. schwiibischer Aerzte, i, 120. 9. Ferro, Med. Arch, von Wien vom 
Jahre 1800, 22. 10. Hildenbrand in med.-chir. Ztg., iSoo, ii, 186. 11. 
Wolff in Iluf. J., ix. Heft 4, 92, x. Heft i, 97. 12. Salomonsen, Udsigt 
over Kjobenh. Epid. Ivjob., 1854, 68. 13. Gilibert in Rec. des actes de la 


Soc. de Sante de Lyon, ii, 369. 14. In Lond. Med. and Phys. Joum., 1805^ 
xiii, 489. 

1801.— I. Sigaud, Maladies du Bresil, 185. 

1802-1803. — I. Jonas in Huf. J., xx, Iloft I, 113. 2. In Journ. gen. 
de Med., xvi, 129. 3. Double ibid., 179, 291. 4. Mojon in Mem. della 
Soc. med. di Geneva, ii, Nr. 2, 80. 5. Klees in Huf. J., xvi, Heft 4, 71. 
6. Horst ibid., xvii. Heft I, 68. 7. Kortuni, ibid.,xx, IToft 3, 15. 8. Witt- 
mann. Die neuesten am Rheine herrschenden Vollcskrankheitcn, etc. Mainz, 
1811,6. 9. Fischer in Allg. med. Annal., 1804. Corrsbl., i. 10. Pearson, 
Some Observ. on the Present Epid. Catarrh. Fever, etc., London, 1803. 
II. Hooper, Observ. on the Epid. Disease, etc., London, 1803. 12. In 
Duncan, Annals of Med., viii, 410, 424, 437. 13. In London Jled. and 
Phys. J., ix, X, xi, passim. 14. In Annal de la Soc. de Med. de Mont- 
pellier, i, 201, iv, 129, vii, 153, 162. 15. Viauld, Ess. sur. . . les 
epid. catarrh., etc. Par., 1803. 16. Brunct Tabl. hist. . , de I'epid. 
catarrh., ibid. 17. Billeray, Serie des propos. sur I'epid. catarrh, etc., ibid. 
18. Cerri, Del catarrho epid. (in Ozanam. i, 202). 19. Gautieri in Hufel. 
J., xvii, Heft i, 54. 20. In Mem della Soc. med. di Geneva, ii, Nr. 2, 100. 
21. Corradi, Annali delle epidemie. v, 538. 22. Thompson, Annals of In- 
fluenza, 202, 23. Kopp, Topogr. der Stadtllanau Frankf. a. M., 1807, 147. 
24. Marc d'Espine, 1. c. (ad ann. 1788) after Peschier. 

1804. — I. Hjaltelin, 1. c. (ad ann. 1729). 

1805-1806. — I- Kerksig in Huf. J., xxiv. Heft 2, no. 2. Harless in 
N. J. d. ausl. med.-chir. Liter., iv. Heft ii, 160. 3. Frank, Act. inst. clin. 
Vilnens. Ann. i, 27. 4. In Leroux J. de Med., 1806, Juli 30. 5. Gaudi- 
chon, Ibid., 39. 6. Chavassieu d'Audebert, Des inondat. d'hiver et d'ete, 
etc. Par., 1806. 7. Py in Annal. de Montpell., vii, 225. 8. Cabiran, Rap- 
port. . . sur I'epid. catarrh., etc. Toulouse, 1806. 9. Amestin, Diss, sur 
les affect, catarrh., etc. Par., x8o6. 10. Larue, Rem. sur I'epid. catarrh., 
etc. Par., 1806. 11. Chiappa, Sagg. d'istor. sull cataro epid., etc. Lucca, 
1806. 12. Double in Journ. gen. de Med., xxvii, 3. 13. Forstrom in 
Svensk. Lak. Sallsk. Handl., iv, 231. 14. Corradi, Annali dellc epidemie, v, 
578. 15. Marmy et Quesnoy, Topogi'. et statist, med. du Dpt. du Rhone, 
etc. Lyon, 1866, 183. 

1807. — I. Drake, Treatise on the Principal Diseases of the Interior Valley 
of North America. Philad., 1854, ii, 809. 2. Jackson in Massachusets' Med. 
Communications, ii, Nr. 2. 3. Gallup, Sketches of the Epidemic Diseases of 
the State of Vermont. Bost., 18 15. 

1807-1808. — I. Bateman in Edinb. Med. and Surg. J., iv, 239. 2. Clarke, 
ibii., 429. 3. Robertson in Lond. Med. and Phys. Journ., xxi, 275. 4. 
Wood, ibid., 323. 

1811.— I. Sigaud,]. c., 185. 
' 1815-1816.— I. Warren in New Engl. J. of Med., v, 165. 2. Hayns- 
worth in N. Y. Med. Repos., New S., iv, 3. 3. Ives in Transact, of the 
Med. Soc. of New York, i. 4. Sigaud, 1. c. 5. Hjaltelin, 1. c. (ad ann. 

1824-25.— I. Dewees in Philad. Journ. of Med. Sc, 1825, N. S., i, 66. 

1826.— I. Jones in Philad. J. of Med. and Phys. So., 1826, N. S., iv, r. 


2. Tbid., V, 414. 3. Heustis in Amev. J. of Med. Sc, 1S2S, 'Jlay. 4. 
Smith in Edinb. Med. and Surg. J., Ivii, 360. 

1827- — I. Rehmann in Huf. J., Ixiv, Heft v, 119; Heft vi, 127, and in 
Jleclcor, "Wissonschaftl. Annal., xix, 122. 

1830-1832- — I. Bennet in Lond. Med. Gaz., vlii, 52,^. 2. KoUmann in 
Heckor, Wissensch. AnnaL, xxvi, 3S9. 3. "Ward in Calcntt. Med. Transact., 
Ti, 124. 3a. Ileymann, Versucb, etc., 159. 4, Bluhni in Verm. AbhandL 
Petersb. Aerzte, v, 13. 5. Sabmen, ibid., 36. 6. Bidder in Hamb. Mag. d. 
jirztl. Lit., xxvi, 51. 7. Trafvenfclt in Arsber. om Svensk. Lak. Sallsk. 
Arbet., 1833, 44. 8. Bremer in Kongl. med. Selsk. Skrift., i, 213 nnd 
Blbl. for Lager, 1847, Nr. 3, 3. 9. Oernstrup, ibid., 1832, i, 228. 10. In 
E.idius,Cboleraztg., Nr. 82. 11. In A'erbandlungen d. pliys.-med. Gesell- 
scb. in Konigsb., ii, 132. 12. Sanitatsber f. die Prov. Brandenburg, v. 
J., 1831,11. 13. Horn in Hom's Arch., 1832, ii, 747. 14. Philippson, 
Die Sommerkrankh. im Jahre 1831, Berlin, 1832, 119. 15. Sanitatsber. v. 
Schlesien f. d. J. 1831, 33, 6;^. 16. Physicatsber. d. Konigr. Saclisen f. d. 
J. 1831, u. 32, 20. 17. Jancovius, De febre catarrh, epid., etc. Lips. 1831. 
18. Report of the Rhen. Med. Collegium for the year 1831, 24. 19. Hey- 
felder in Med. Conversationsbl., 1831,363. 20. Giinther in Med.-chir. Ztg., 
1832,1,204. 21. Krimers in Huf- J., Ixxix, Heft ii, 12. 22. Speyer, ibid.. 
Heft i, 92. 23. Lebrecbt in Rust's Magaz., xxxv, 195. 24. Puchelt in 
Heidelb. klin. Annal., viii, 518. 25. In Wiirttb. med. Corrsbl., i, 4,71, 151, 
262, 301, iii, 277. 26. Rosch in Clarus, Beitr. zur pr. Heilkde., ii, 222. 
27. Pfeufer in Med. Annal., ii, 218. 28. Heidenreich, Die Influenca, etc. 
Ansbach, 1831. 29. In Oest. med. Jahrb. Neueste F., vii, 205. 30. Zlata- 
rowich, ibid., iii, 351. 31. Kahlert in Clarus, "Wochentl. Beitrage, i, 171. 
32. In Bibl. univ. des Sc, xvii, 51. 33. Lombard in Gaz. med de Paris, 
1883, Nr. 70. 34. Fuster, ibid., 1232, 114. 35. Campaignac, Consider, sur 
la grippe. Par., 1831. 36. Buet in Journ. coraplem. du diet, des Sc. med., 
^^» 55- 37- 1° Seance publ. de la Soc. de Toulouse, 1837, 106. 38. In 
Lond. Med. and Phys. J., Ixvi, 179. 39. Oswald, ibid., Ixvii, 15. 40. Renzi 
in Omodei Annal., Ixii, 5S5. 41. Tonelli, ibid. 42. Folcbi, ibid., 57. 43. 
In Clarus, Wochent. Beitr., i, 95. 44. In American J., 1832, Febr. 45. 
Baldwin, ibid., Nov. 46. In Calcutta Med. Transact., vi, 473. 474. vii, 294. 
47. Turner, Nineteen Years in Polynesia. Lond., 1861, 536. 48. Corradi, 
Annali delle epidemie, v, 938, ff. 49. Lawson, Lond. Med. Times, 1831, viii, 
525. 50. Espy in Amer. Journ. of Med. Sc, 1833, Febr., p. 541. 51. 
Stosch in Casper, Wocbenscbr., 1833,1,449. 52. Chevalley, Gaz. med. de 
Paris, 1834, 252, 53. Meynne, Topogr. med. de la Belgique. BruxelL, 
1865, 235, 54. Franque in Med. Jahrb. f. d. Herzogth. Nassau, 1859, 
Heft 15 u. 16, 235. 

1833. — I. Pi-uner, Die Krankh. des Orients., 30S. 2. In Clarus, Wochentl. 
Beitr., i. 367. 3. Licbtenstadt, ibid., i, 207. 4. Blosfeld in Huf. J., Ixxviii, 
Heft 6, 27. 5. In Clarus, Wochentl. Beitr., ii, 375. 6. Ronander, in Tidskr. 
for Lak. ocli Pharmac, 1833, Nr. 5. 7. Trafvenfelt, ibid., Nr. 7. 8. Thel- 
ning in Svensk. Lilk. Siillsk., nya Hdl., ii, 99. 9. Bremer, 1. c (1S31). 
10. Ballin in Clarus w. Beitr., iii, 89. 11. In J. for Sled, og Chir., ii, 70. 
12. Trier, ibid., ii, 209. 13. Leth, ibid., ii, 2C6. 14. Wahl, ibil., vi, 302. 


15. In Clarus w. Boitr., ii, 15, and BeitrJige z. pract. Hcilkd., i, 317. 16. 
Slnagowitz in Rust. Mag., xl, 56. 17. Richter in Clavus w. Beitr., i, 377. 
iS. In Huf. J., Ixxvi, Heft 3, 120. 19. Carganico in Rust. Mag., xl, 403. 
20. Berndt, Klin. Mittli., ii, 46. 21. Liebnmnn, Diss de influenca, etc. 
Xjiyph., 1S34. 22. Sanitjitsbericht von Schlesien f. 1833, i, 36. 23. 
Wentzke, Die Influenca, etc. Breslau, 1833. Cohen in Casp. Wochenschr., 
1833, ii, 609. 25. SanitJitsber. fiir die Prov. Brandenburg vom J. 1833, 
17. 26. Kriiger, Diss, de influenca cpid., etc. Berlin, 1S34. 27. Stoscli in 
Casper Wochenschr., 1833, i, 419. 28. In Clarus wochentl. Beitr., ii, 31. 
^9. Wolff in Pr. med. Vrs.-Ztg., 1833, Nr. 19. 30. Boehr, ibid. Nr. 20. 
31. Steinthal in Horn Arch., 1833, ii, 670. 32. Horn, ibid., 847. 33. 
IMeyer, Die Influenza des Jahres 1833. Potsd., 1833. 34. Medicinalber d. 
Pro\'. Sachsen f.d. J. 1833, 30. 35. lu Pfaff MittheiL, N. F., i., Heft i, 29 ; 
Heft 5, 23; ii. Heft 4. 41. 36. Hachmann in Hamb. Mitth., ii, 284. 37. 
Busch in Huf. J., Ixxviii, Heft 6, 3. 38. Droste in Clarus w. Beitr., ii, 277. 

39. Fischer in Huf. J., Ixxix, Heft 4, 59. 40. Physicatsber. d. Konigr. 
Sachsen f. d. J. 1833, u. 34, 51. 41. In Clarus wissensch. Beitr., ii, 95, 11 r, 
140, 191, 223, 320, and Beitr. z. pract. Heilk., i, 86. 42. Radius, De 
influentia morbo Anni 1S33. Lips., 1833. 43. Haser, De influentia epid. 
Diss. Jena, 1834. 44. Schneider in Heidelb. kl. Annal., ix, 364, and 
Schmidt Jahrb., iii, 330. 45. Heusinger, ibid , i, 84. 46. Report of the 
Shen. Med. Coll. for 1833, 17. 47. Giinther in Med.-Chir. Ztg., 1834, i, 
240, and Huf. J., Ixxviii, Heft vi, 25. 48. Rolffs, Das epid. Catarrhalfieber. 
Koln, 1833. 49. Bluff in Heidelb. kl. Annal., ix, 375. 50. Puchelt iu 
Med. Annal., i, 549. 51. In Wiirttb. med. Corrsbl., ii, 60, 76, 100, 104, 
114, 178, 180. 52. Hejfelder in Schmidt Jahrb., viii, 106. 53. Dietrich 
in Clarus w. Beitr., iii, 247. 54. Martin in Schmidt Jahrb., xiii, 86. 55. 
Friedereich, ibid., i, 369. 56. Hergenrother in Bayr. med. Corrsbl., 1840, 

40. 57. Klug, Ueber die Krankheitsconstitution des Jahres 1834. Wiirz- 
burg, 1835. 58. Eschericht, Die Influenza, etc. Wiirzb. 1833. 59. Biich- 
ner. Die vier Grundformen des epidemischen Krankheitsgenius, etc. Er- 
langen, 1836, 57. 60. Ref. in Oest. med. Jahrb., N. F., xi, 28. 61. 
Eiselt, ibid., v, 610. 62. Kahlert in Clarus w. Beitr., iii, 81. 6^. Fried- 
Ijinder in Oest. med. Jahrb., Nst. F., xiii, 349. 64. Ibid., ix, 368. 65. 
Knolz, ibid., ix, 197. 66. Viszanik, Abhandl. iiber die Epid. d. Masern und 
Grippe, etc. Wien, 1833. 67. Zlatarovich, Gesch. d. epid. Catarrhs, etc. 
Wien, 1834. 68. Streinz in Schmidt Jahrb., v, 329. 69. In Oest. med. 
Jahr., Nst. F., xi, 191. 70. In Med.-chir. Ztg., 1833, iii, 29, no, 174. 71. 
In Clarus w. Beitr., ii, 170, Beitr. z. pract. Heilkde., i, 174. 72. In 
Oest. med. Jahrb., N. F., xi, 509. 73. Ibid., xii, 19. 74. Windisch in 
Schmidt Jahrb., iii, 203. 75. Eckstein, ibid., 217. 76. Zsclrokke in Pommer 
Zeit.schr.,i, 337. 77. Gelpke, De influentia epid. Turici, 1834. 78. Blosch 
in Schweiz. Zeitschr. f. Med. 1848, 323. 79. Brierre de Boismont, Consider, 
prat, sur la grippe, etc. Par. 1833. 80. Gaudet in Gaz. med. de Paris, 
1833, Decbr. 81. Ibid. Nr. 45, 48. 82. Richelot in Arch, gen., 1835, 
Mars., Aout. 83. Lemercier in Bullet, gen. de therap., 1833, Novbr. 
84. In Expose de trav. de la Soc. des Sc. med. du Dpt. de la Moselle 1831- 
,38, Iviii. 85. In Notice des trav. de la Soc. de Med. de Bordeaux, 1834. 



86. In Oest mcd. Jalirb., X. F., xiii, 343. 87. Tinelli in Omodei Annali, 1833, 
Oct. 88. Steer, ibid., Juli. 89. Galli in Report, med.-chir. del Piemonte, 
1834, Marzo 117. 90. In Clar. w. Beitr., ii, 239. 91. Ibid., iii, 287. 92. 
Eivaz in Gaz. mod. de Paris, 1834, Nr. 16. gs- I" I^ond. Med. Gaz., 1833, 
xii, 62, 124, 156. 94. Hingeston, ibid., 198. 95. Parson in Provinc. Med. 
Transac., ii. 96. Brown in Edinb. J., xliii, 26. 97. Colvin in Dubl. J. of 
Med. Sc., iv, 183. 98. Corradi, Annal. delle epidemie, etc., v, 953. 99. 
Luber, Beschrijving van de ziekten te Amsterdam, etc. Amsterd., 1861. 
100. Franqne, 1. c. (ad ann., 1831). 

1834.— I. Segond in Journ. bebd. dc Med., 1835, Nr. 12. 2. In Revista 
med. Flnmin., 1835. Dez. 3. In Indian Journ. of Med., i, 67, 146. 

1836-1837.— I. In Lond. Med. Gaz., xx, 129. 2. Ibid., 115. 3. Heine 
in Sebmidt Jabrb., xvii, 227. 4. Retzius in Svensk. Liik. Siillsk. nya. Ilandl., 
ii, 263. 5. Bremer, 1. c. 6. In Bibl. for Lager, 1839, i, 88. 7. Horesens,. 
ibid., 253. 8. Otto in Hamb. Ztsebr. f. Med., v, 180. 9. Sanitatsber. f. d. 
Prov. Preu.ssen, 1S37, i, 10. 10. Benidt, Klin. Mittbeil.. Heft 3 n. 4, 87. 
II. In Pfaff Mittbeil, N. F., iii, Heft i u. 2, 92 ff. 12. Zinimermann, ibid.. 
Heft 5 u. 6,1. 13. Bebre, ibid., Heft 9 und 10, 64. 14. Assing in Hamb. 
Ztschr. f. Med., iv, 441. 15. Warburg, ibid., ix, 2. 16. Sanitatsber. f. d. 
Prov. Brandenburg ilber d. J. 1837, 20. 17. Steintbal in Horn Arcb., 1837^ 
i, 245. 18. Henschel in Clarus Beitr. z. pract. Heilkd., iv, 311. 19. Scble- 
sier in Pr. med. Yrs.-Ztg., 1837, Nr. 20. 20. Dvirr in Clarus Beitr., iv, 90, 
21. Ibid., 206, 330. 22. Haeser in Allg. med. Ztg., 1837, Nr. 23. 23. 
Scli-svarz in Med. Annal., iv, 123. 24. Scbneider in Huf. J., Ixxxvii, Heft 
3, 9. 25. Ebel, ibid,, Ixxxiv, Heft 6, 3. 26. Fischer, ibid., Ixxxvii, Heft 
5, 33. 27. Braemer in Allg. med. Ztg., 1837, Nr. 21. 28. In Casper 
Wocbenscbr., 1837, Nr. 14. 29. Laporte in Hannov. Annal., iii, 30. 30. 
Sanitatsbericbt d. Rhein. Med.-CoUeg. iiber das J. 1837, 9. 31. Ebermaier 
in Casp. Wocbenscbr., 1837, 212. 32. Albers in Horn Journ., 1837, i, 202. 
33. Giintber in Hiif. J., Ixxxiv, Heft ii, 124, and Med.-cblr. Ztg., 1838, i, 
383. 34. Notices in Wiirtt. med. Corresbl., vii, 48, 56, 64, 70, 88, 95, 104, 
112, 136, 159, 207, 359, 386, 507, 153 and 295, 337, viii, 278, xi, 177. 35. 
Cless, ibid., vii, 257, 273. 36. Heyfelder in Med. Annal., iv, 238. 37. 
Hergenrotber, 1. c. (1833) 60. 38. In Oest. med. Jabrb. Nst. F., xx, 332. 
39. Sterz, ibid., xiii, 547. 40. In Huf. J., Ixxxiv, Heft iv, 113. 41. Feucb- 
tersleben in Med. Centralztg., 1837, Nr. 14. 42. Hornung, Jabresber., etc. 
Salzb., 1840, 71. 43. In Pommer Zeitscbr., iii, 231, 326, iv, 337, ^(^6, v, 
334, vi, 133. 44. Report of the Sanitary Council of Ziiricb for 1837, 35. 
45. Bloscb in Schweiz. med. Zeitscbr., 1848, 325. 46. Streeten in Prov. 
Med. Transact., vi, 501. 47. In Lond. ]\Ied. Gaz., xix, 586 ff. 48. In Lancet, 
1837, Febr. 49. Blakiston, A Treatise on the Influenza of 1837. Lond., 
1837. .50. Greenhow in Lond. Med. Gaz., xix, 623, xx, 9. 51. Morrison in 
Dubl. J. of Med. Sc, xiii, 249. 52. Graves in Lond. Med. Gaz.,xx, 785, 856,. 
and Clinical Medicine. Dublin, 1843, 541- 5.3- Gouzce in Bullet, med.. 
beige, 1837, Fevr. 26. 54. Petrequin in Gaz. mod. de Paris, 1827, Nr. 51. 
55. Piorry, ibid., Nr. 6, 7. 56. Gras in Journ. des connaiss. med., 1837, Nr. i. 
57. Tancbon, ibid., Nr. 2. 58. Landouzy in Journ. des connaiss. mcd.-clur.,. 
1837. Nr. 6. 59. Gouraud, ibid., Nr. 3. 60. Sandras in Bullet, gen. de tberap.,. 


1837, Nr. 2, 4, 17. 61. Yigla in Arch, gen., 1837, Fevr. 62. Hourman, 
ibid., Mars. 6;^. Landau, ibid., Avril. 64. Grissolle in Prcsse mod., 1837, 
Nr. 13. 65. Valloix, ibid., Nr. 15. 66. Lereboullet, Eapp. sur. I'cpid. dc 
Grippe, etc. Paris, 1838. 67. Scbiitzenberger in Arch. med. de Strasb., 
1837, Nr. 23, 24. 68. Toulmouche in Gaz. med. de Paris, 1847, Nr. 44, 858. 
69. Simonin, Rech. topogi-. et mod. sur Nancy, 180. 70. In Expose des trav. 
de la Soc. des Sc. rued, du Dpt. de la Moselle, 1831-38, 167. 71. Kosciakie- 
wicz, Mem. sur I'epid. de Grippe, etc. Lyon, 1840. 72. Pointe in Giora. 
delle Sc. med. di Torino, v, i. 73. Gubian, Hist, de la Grippe, etc. Lyon, 
1837. 74. In Compt. rend, des trav. de la Soc. de Med. d. Lyon, 1836-38, 
90. 75. Levi-at in Seance publ. de la Soc. de Med. de Toulouse, 1839, 
71. 76. Py, ibid., 1837,72. 77. Cany, ibid., 33. 78. Lavit, ibid., 1838, 93. 
79. Milon, ibid., 65. 80. In Compt. rend, de la Soc. de Med. de Lyon, 
1836-38, 106. 81. In Prec. analyt. des trav. de la Soc. med. de Dijon, 
1834-37,27. 82. Burguet in Revue mod., 1838, Juill., 147. 83. Caisergues, 
ibid., 1840, Sept. 411. 84. Bonino in Giorn. delle Sc. med. di Torino, v, i. 
85. Girelli, Dell catarro epid., etc. Milano, 1840. 86. In Bullet, delle Sc. 
med. di Bologna, 1837, Nr. 5, 6. 87. Sorgoni, ibid., 11, 12. 88. Eonchetti, 
Diss, de causis . . . catan-h. epid., etc. Ticino, 1837. ^9- Ticozzi, Diss. 
in catarrh, epidem., etc. Ticin., 1837. 90. Leitao in Jorn. das Sc. med. 
de Lisboa, v, Nr. i . 91 . Franco, ibid., Nr. 2. 92. In Wiirttbg. med. Corrsbl., 
ix, 291. 93. Pruner, 1. c, 208. 94. Andrade in Period, de la Acad. de. Med. 
de Megico, 1837, August. 95. Meynne, 1. c. (ad. ann. 1831). 96. In Arch, 
de med. nav., 1868, x, 415. 97. Luber, 1. c. (ad. ann. 1833). 98. Franque, 

1. c. (ad ann. 1S31). 99. In Casper Wochenschr., 1837, 231. 100. Statist. 
Ecports on the Health of the British Navy for the years 1837 to 1843. 
Lond., 1854, iii, 7 (Outbreaks on board English ships of war cruising off the 
coasts of Spain and Portugal). loi. Lombard in Gaz. med. de Paris, 1837. 
102. Black in Lond. Med. Gaz., 1838, N. S., i, 23. 103. Jefferey in Transact, 
of the Prov. Med. and Surg. Association, 1843, ^^> 209. 104. Statist. Eep. 
on the Health of the Brit. Navy, etc. Lond., 1853, ii, 8. 

1838-1839.— I. Follet in Bullet, de I'Acad. de Med. (Gaz. Med de Paris, 
1840, 332.) 2. Petit, Voyage en Abyssinie, etc. 3. Panum, Bibl. ^for 
Lager, 1847,1, 311. 4. Hjaltelin, I.e. 5. Eeports on the Health of the 
Navy, ii. 14. 

1841. — I. Sanitatsbericht des Prov. Preussen, 1841,], 21. 

2. Ivocher, Diss, de catan-ho epid., etc., Kiel, 1841. 3. Physicatsbericht des 
Konigr. Sachsen f. d. J. 1840 und 1841, 105. 4. Schlesier inPr. med. Vrs.- 
Ztg., 1841, Nr. 37. 5. Schneider in Huf. J. xcii. Heft 6, 66. 6. Weiss, 
Diss, exhib. decenn. clin. in acad. Jenensi, etc., Jen. 1841, 25. 7- Miinchmeyer 
in Hannov. Annalen, N. F., 549. 8. Eeport of the Ehen. Med. Colleg. for 
the year 1841, 40. 9. Eckstein in Oest. med. Jahrb., 1841, Juli 22. 10, 
V. Wirer in Verhandl. der Wien. arztl. Gesellsch., i, 375. 11. Brady in 
Dubl. J. of Med. Sc, xx, 76. 12. Jackson in Dubl. Med. Pres., viii, 6g. 13. 
Eeport of the Med. Coll. of the Prov. of Westphalia, 1841, 23. 14. 
Franque, 1. c. (ad ann. 1831). 

1842- — I. Labeau in Bullet, de I'Acad. de Med. de Belgique, ii, 121. 2. 
In Bullet, gen. de therap., xxii, 137. 3. In Gaz. des hopit., 1842, Nr. 52. 


4. Eoss in Lancet, 1845, i, 2. 5. Lavcock In Dubl. Med. Press, vii, 234. 
6. rriiner, 1. c, 308. 7. GilHs, Deutsche Klin., 1856, 247. 

1843.— I. Middendoi-f in Med. Ztg. Eussl., 1844, Nr. i. 2. lu Huf. 
J., xcv, Heft 4, 108, Heft 5, 116. 3. Sanitatsbericht d. Med. Colleg. 
von Westfalen fiir d. Jabr 1843, 33. 4. In Gaz. med. beige, 1843, Xr. 14. 

5. Ibid., Nr. 16. 6. Report of the Council of Health for Canton Ziirich, 
1843, 18. 7. In Amer. J., 1843, Juli. 8. Coolidge, Army Statist. Eepoi-ts, 
Pbilad., 1S56, 21, 33, 35, 47, 81, 147, 150, 158, 170, 251, 265. 9. Forry in 
N. Y. J. of Med., 1843, Xov. 10. Gilbert, ibid. (Lond. Med. Gaz., 1844, 
Febr., 703). 11. Hjaltclin, 1. c. 12. Peebles in Amer. J. of Med. Sc, 1S44, 
April, 362. 

1844.— I. Sanitatsber. d. Ehein. Med. Coll. f. d. J. 1844, 7. 2. Sanitats- 
ber. d. Med. Coll. von Westfalen f. d. J. 1844.442. 3. Hall in Prov. 
Med and Surg. J., 1844, Nr. 151. 4. Nolhac in Journ. des connaiss. mdd.- 
chir., 1844, Juin. 5. Thielmann m Med. Ztg. Eussl., 1845, 245. 6. 
In Gaz. med. beige, 1844. 212. 7. Franque, 1. c. 8. Marc d'Espine, Gaz. 
med. de Paris, 1. c. 9. Thomson, Brit, and For. Med.-Chir. Eeview, 1855, 

1845.— I. Sanitatsbericht d. Med. Colleg. v. Westfalen f. d. Jahr 1845, 
42. 2. In Schwz. Zeitschr. f. Med., 1847, 234, 321. 

1846-1847.— I. Churchill in Dubl. Quart. J. of Med., 1847, May, 
373. 2. In Sundhedskoll. Forhandl. for Aaret 1847, 9. 3. In Hamb. 
Zeitschr. f. Med., xxxvii, 104. 4. Putegnat in Journ. de Med. de Bruxell, 

1847, Juin, 440. 5. Jung in Sehweiz. Zeitschr. fiir Med., 1848, 228. 
6. Thielmann in Med. Ztg. Eussl., 1847, 147. 7. Blosch in Sehweiz. 
Zeitschr. f. Med., 1848, 326. 8. In Seance publ. de la Soc. de Med. 
de Toulouse, 1847, 153. 9. Laval in Gaz. med. de Paris, 1847, Decbr. 10. 
In Gaz. med. de Paris, 1847, 21, 61. 

1847-1848.— I. Tbomsen in Hamburger Zeitschrift f. Med., xl, 389. 1 a. 
Scholwin in Med. Ztg. Eussl., 1848, Nr. 42. 2. In Prag. Viertelj. f. Med., 
XXV, 90. 3. Canstatt, ibid, xsiii, 92. 4. In Wiirttb. med. CoiTsbl., xix, 13, 
35, 208. 5. In Sundhedskoll. Forhdl. for Aaret 1848, 11. 6. In Cohen 
Statist.-geneesk. Jaarboek voor 1848, iMSshn. 7. Galama in Pract. Tijdschr. 
voor de geneesk., i, 137. 8. Marc d'Espine in Gaz. med. de Paris, 1848, 
Mai, and Sehweiz. Ztschr. f. Med., 1849, 399. 9. In Gaz. med. Lombardia, 

1848, 24, 36, 47, 58, 68, 174. 10. In Lond. Med. Gaz., 1847, v. 980. 11. 
Peacock, On the Influenza, etc., Lond., 1S48. 12. Webster in Lond. Med. 
Gaz., 1S4S, Febr. 13. Laycock, ibid., 1S47, Dec, 1053. 14. Ibid., 1037. 
15. Stark in Edinb. J., Ixix, 263. 16. Ibid., 378. 17. Bertrand, Mem. 
sur la topogr. mod. du Dpt. du Puy-de-D6me. Clermont, 1849, 166. 18. 
Maffoni in Giorn. med. chir. di Torino, i, Xr. 2. 19. Trompeo, ibid. 20. 
In Lond. Med. Gaz., 1847, v, 1152. 21. In Sundhedskoll. Forhdl. for Aaret 
1848, 15. 22. Hunter in Lond. Med. Gazette, 1849, ^^' ^^7- 23. Toul- 
mouche, 1. c. (ad ann. 1837). 24. Bouchaeourt in Journ. de med de Lyon, 

1847, I^ecbr. 25. Hannover, Statist. Undersogelsor, etc., Kjobeuh., 1S5S, 
125. 26. Luber, 1. c. (ad ann. 1837). 27. Gairdner, Clinical Lectures, 
Edinb., 1862, 100. 28. Franque, 1. c. 29. In Gaz. med de Paris, 1S47, 977, 

1848, I. 30. Molo in Bayr. arztl. lutelligenzbl., 1856, 350. 31. Boens in 


Bull, de TAcad, de Med. de Belgique, 1857, xvi, 228. 32. Gulick in New 
York Journ., 1855, March. 

1850-1851. — I. Rufz in Arch, de med. nav., 1869, xi, 426. 2. Piderit in 
Dtsch. med. Klin., 1853, Nr. 48. 3. Gibbons, Annual Address before the San 
rraneisco Med. Soc, 1857, iS. 4. Uroop in Hannov. med. Correspdzbl., 
1 85 1, ii, 165. 5. Franque. 1. c. 6. Blum in Hannov. med. Correspdzbl., 
1853, iv, 51. 7. Svenska Suudhets-Coll. Berattelse &ret 1851, 160. 8, 
Molo, 1. c. (ad ann. 1848). 9. Beaugrand in Journ. des conn. med. prat., 
1851, Mars. 10. Gucrin in Gaz. med. de Paris, 1851, 199. 11. Facen, 
Annal. univ. di Med., 1858, Marzo. 12. Griesinger, Arch, fiir physiol. 
Heilkd., 1853, xii, 547. 13. Popper, Zeitschr. fiir Epidemiologic, 1876, ii, 288., 

1852- — I. Hall, Transact, of the London Epidemiol. Soc, 1865, ii, 85. 2. 
Piderit, 1. c. (ad ann. 1 850-1 851). 

1853. — I. Scherzer in Zeitschr. der. Wien. Aerzte, 1858, 165. 2. Danske 
Sundhetskoll. Aarsberetning for 1853, i, 29. 

1854. — I. Hoffmann in Bayr. arzl. Intelligenzbl., 1854, 241. 

1855. — I. Krebel in Med. Ztg. RussL, 1855, 4°i' 2. Molo, 1. c. (ad ann. 
1S4S). 3. In Bayr. jirztl. Correspdzbl., 1855, 178, and Wiirttb. med. Cor- 
respdzbl., 1855, 31, 55, 103. 4. Waardenburg in Nederl. Tijdschr. voor 
Geneesk., 1858, ii, 353. 5. Boens, 1. c. (ad ann. 1848). 6. In Bayr. iirztl. 
Intelligenzbl., 1855, 343. 7. Franqne,l.c. 8. Hjaltelin, 1. c. 9. Bollinger 
in Bayr. iirztl. Intelligenzbl, 1858, 266. 

1856- — I. Danske Sundhetscoll. Aarsberetning for 1856, 62. 2. Ibid., 66. 

1857-1858. — I. Horner in Amer. Journ. of Med. Soc, 1859, ^pi'il^ 362, 
2. lb. 3. In Statist. Report of the Health of the Brit. Navy for the year 
1857, 41. 4. Bursy in Med. Ztg. Eussl., 1859, 229. 5. Herrmann in 
Petersb. med. Zeitschr. 1861, 354. 6. Ucke, Das Klima und die Krank- 
heiten der Stadt Samara. BerL, 1863, 232. 7. Franque in Med. Jahrb. fiir 
das Herzogth. Nassau, 1863. Heft xix u. xx, 201. 8. In Wiirttb. med. 
Correspdzbl., 1858, 12, 48, 187,302,318; and Kostlin ib., 1859, 187, 193. 
9. Schmidtmiiller in Bayr. Jirztl. Intelligenzbl., 1858, 151, ib. 1859, 322 ; 
Majer ib. 1859, 475. 10. Meynne, 1. c. (ad ann. 1831). 11. In Gaz. med. 
de Paris, 1858, 57, 93. 12. Ib., 21 ; Bossu, Abeille med., 1858, Nr. 6 ; in 
Gaz. des hopit., 1858, Janv. 16 ; Edmond, De la grippe. These, Par. 1858, 
13. Massin, Epidemic catarrhale de 1858. These, Strasb., 1858 ; Forget in 
Gaz. med. de Strasbourg, 1858. 14. Marmy et Quesnoy, 1. c (ad ann. 1800), 
564. 15. Granara in Annali univ. de Med., 1858, Febr. 16. Danske 
Sundhetscoll. Aarsberetninger for 1&58. 17. Popper, 1. c. (ad. ann. 1850-51). 

I860.— I. Hall, 1. c. (ad ann. 1852). 2. Statist. Ptcport on the Health of 
the Brit. Navy for the year i860, 181. 

1861. — I. Levick in Amer. Journ. of Med. Sc, 1864, Jan. 65. 

1862- — I. Statist. Kep. of the British Army for the year 1862, 61. 2. 
In Nederl. Tijdschr. voor. Geneesk. 1S63, vii, 461. 3. Lawson in Transact, 
of the London Epidemiol. Soc, 1867, ii, 290. 4. Hjaltelin, 1. c. 

1863-1864.— I. In Arch, de med. nav., 1866, v, 23. 2. Union med., 
1864. 3. In San Francisco Med. Press, 1864, April. 4. Jahresbericht 
iiber die Verwaltung der Medicinalwesens . . . des Cantons Ziiricli im 
J. 1864, 115. 


1866- — I. Giiignoii in Eec. de med. milit. 2. Bailly in Bull de I'Acad. 
de Med., xxxiii, iSfiS, 471. 3. Mercurin, Eelatiou med. d'un hivernage a 
rile Maurice (1866-67). Montpell., 1868, 9. 

1867. — I. Moutard-Mai-tin in Gaz. des liopit., 1867. Nr. 26, 29. 2. 
Petit, ib. Nr. 37. 3. Besnier, Union med., 1867. Nr. 19, 31. 4. Eisscn, 
Gaz. med de. Strasb., 1867. Nr. 5, 7. 5. Kostlin in Wiiiitb. med. Cor- 
respdzbl., 1868, 351. 6. In Bull, de la Soc. de mt'd. de Gand 1868, Janv. 

1868. — I. Marroin in Arch, de med. navale 1869, xir, 464. 

1871- — I- Egan in Med. Times and Gaz., 1872, i, 112. 

1873. — In Philad. Med. and Surg. Reporter, xxviii, 1873, i, 275. 

1874-1875. — I. Ibid., xxxii, 1875, i, 119, 201. 2. Carriore in I'Union 
med., 1875, i, 713, 738. 3. Besnier, ib. 1875, i, 622. 4. Lapie, Eelation 
d'une epidemie de grippe abdominale. Paris, 1S76. 5. 3Ieynet in Lyon 
medical, 1875, i, 469. 6. Sveriges Sundliets-Collegii Beriittelse for Sr 
1875. 25. 



§ 12. A Comparatively New Disease : its Symptoms. 

Under the name Dengue,^ the West Indian and United 
States physicians have described a peculiar disease which 
appeared as an epidemic in 1827—28 in the West Indies, 
on the seaboard of the Gulf of Mexico, and on the Atlantic 
coast of the Southern States of the Union ; this disease 
attracted general attention both by the novelty of its 
form and by the enormous extent of its prevalence. Sub- 
sequent inquiries showed that the disease had occurred before 
at various parts of the globe. But it was not until the 
general outbi-eak of the disease in 1871—73 in the tropical 
regions of the Eastern Hemisphere that the learned world 
of medicine began to take much interest in it ; and that 
is the period that gave rise to the excellent series of medical 
accounts which have furnished the desired information as to 
the peculiarities of the disease. Considering the small notice 
taken of dengue in German medical literature hitherto, I 
think it necessary to preface the account of the important 
points in its history, geography, and etiology, with a brief 
sketch of the disease itself. 

^ Men's wits have been taxed to find names for tliis disease. Thus the 
Spaniards called it dengue (corresponding In meaning to the French minau- 
derie, and the English dandy) or Colorado ; the English and Americans have 
called it breah-bone and broken-ioing, the French giraffe and bouquet (whence 
the English corruption bucket), and the Brazilians polka fever. By the 
medical profession the disease has been named, according to the view taken 
of its nature, rheumatismus febrilis exanthematicus, scarlatina mitis, exan- 
thesis arthrosia, and insolation fever ; while some physicians have placed it 
beside f ebris remittens biliosa, or have professed to discover in it a mild form 
of yellow fever. 


After an incubation stage, generall}' of short duration, 
averaging two to four days, and a prodomal stage (often 
wanting) characterised by a feeling of general weakness, 
pains in the head and joints, and gastric troubles, the out- 
break of the disease is announced by chills, followed by a 
hot fit, in which the temperature rises very considerably in 
a few hours, not unfrequently reaching 40° C. (103'5° F.) and 
upwards. At the same time there occur extremely acute 
pains in the joints, at fii'st usually in the smaller joints 
(fingers, hands, and feet), but afterwards in the larger as 
well (knee, elbow, shoulder) ; like the flitting pains of acute 
rheumatism, they often change their seat, and, in severe 
cases, they are so acute that the slightest pressure cannot 
be borne, and the patient is unable to make the least move- 
ment with the affected limb. As the disease develops 
in intensity, equally severe pains are felt in the bones and 
muscles both of the extremities and the trunk, sometimes also 
in the muscles of the eyeball with swelling of the skin and 
redness of the conjunctiva. The tongue is red or coated_, 
and there is usually nausea and not rarely vomiting. The 
patient complains of acute pain in the head and back, and is 
restless and generally sleepless. Severe brain symptoms, such 
as delirium or a comatose state, are unusual ; more frequently 
observed are convulsions in young children, which are not, 
however, of serious import. In about one half of all the 
cases, an exanthem breaks out at this stage of the disease, 
in the form of a more or less uniform or spotted erythema 
which lasts only an hour or two. After this stage has 
lasted from twenty-four to forty-eight hours, a remission 
of the fever sets in and is rapidly completed, accompanied 
often with the outbreak of copious perspiration of a penetrat- 
ing odour ; this is followed by an abatement of the pains in 
the head, the joints, and the muscles, while the swelling 
disappears and much urine is passed, containing a large 
amount of urates. Shortly after there appears a second 
(terminal) exanthem (sometimes with febrile accompani- 
ment), which is more constant than the former or initial 
onCj and takes the form of bright red, slig'htly elevated, 
irregular spots, as in scarlet fever or measles, or it may simu- 
late urticaria or pemphigus ; like the first exanthem, it has 

DENGUE. 57' 

often a dui'ation as short as a few liours^ only exceptionally 
lasting two to three days^ and when it fades there is des- 
quamation. With the outbreak of this exanthem, there often 
occurs swelling- of the lymphatic glands of the neck, axilla, 
or groin ; sometimes also angina, flow of saliva, or an 
aphthous affection of the mucous membrane of the mouth. 
These complications also are very soon over in mild cases 
which run a normal course, and the patient enters on the stage- 
of convalescence after a period of sickness averaging six to 
seven days, being for the most part in a state of great weak- 
ness and anjBmia ; the convalescence is often very protracted 
in consequence of the long continuance of the joint affection, 
and under some circumstances it may go on for months. 

Although the complications in this disease are troublesome, 
yet the prognosis is favourable even in comparatively severe- 
cases. A fatal issue is extremely rare, and is for the most 
part observed only in children, the aged, or those persons 
who are attacked by dengue while suffering from chronic and 
severe organic disease. 

The meagre post-mortem repoi'ts given by a few of the 
observers afford no satisfactory explanation of the nature of 
the disease. The changes found after death in the circula- 
tory and respiratory apparatus are clearly due to other morbid, 
conditions from whicli persons dying of dengue had suffered 
previously. Out of three cases in which a post-mortem 
examination was made, serous infiltration in the neighbour- 
hood of some of the joints was found twice, and in the third 
case the crucial ligaments of the knee-joint were reddened. 

§ 13. Geogeaphical Distribution. , 

The earliest accounts -^ of the epidemic ^prevalence of dengue,. 
and in fact of the occurrence of the disease at all, do not go 
farther back than the last twenty years of the preceding 
century, or beyond the years 1779 and 17S0 ; in these years, if 
we may judge from isolated notices, the disease seems to have 
attained a considerable diffusion in the tropical and sub- 

^ All the authorities are given in tlie alphabetical synopsis of the literature 
of dengue at the end of the chapter. 


tropical parts both of the Eastern and Western Hemispheres. 
" In the eleven hundred and ninety-third year of the Hegira/' 
[i.e. 1779), says the chronicler Gaberti ^ ''in the middle of 
the month Kegeb, there appeared at Cairo and in the neigh- 
bourhood, a disease known as the knee-trouble {ahu rolmh) ; 
it threw all the people into a fever, not excepting even the 
little ones. Its first attack lasted for three days, after which 
the illness increased or diminished, according to the disposi- 
tion of the individual. It was accompanied by pain in the 
joints, knees, and extremities, as well as inability to move, 
and often with swelling of the fingers. The after-pains lasted 
more than a month. The onset was sudden, the body being 
broken by it, and the head and knees taken hold of. The 
disease was cured through sweating, and by the use of the 
bath.'"' According to the statements made to Ehrenberg 
(1. c.) by Dr. Mai-purgo, the sickness was prevalent at the 
same time in Alexandria. For the same year there is an 
account of its prevalence in the month of March at Batavia 
by Bylon," the medical officer of that town, who himself 
sufi^ered from it, and for the year 1780 on the Coromandel 
coast by Persin, a missionary, "A fever of this kmd 
occurred," he says, " on the Coromandel coast about the 
year 1780. Every one was attacked by it. The symptoms 
by which it was ushered in were almost the same as those 
premonitory of the plague — headache, lassitude, pains in the 
joints ; but this epidemic had no bad consequences. The 
patients got rid of it in three days, under moderate diet 
and copious beverages." 

There is another account for the year 1780 by Eush (1. c.) 
of an epidemic of " Bilious Remitting Fever " observed by 
him at Philadelphia in the months from July to October, 
and there can be no doubt that this was dengue fever. For 
the years 1784-88, there are accounts by Cubillas, Nieto de 
Pina, and Fernandez de Castilla of the prevalence of the same 
disease in Cadiz (1784 and 17S8) and in Seville (1784 and 
1785). The description given by these observers (Cubillas 
expressly mentions the exanthem, una esindsion cutanea 

' Quoted by Pruner. 

-. In the ' Verhandel. van het Batav. Genootsch. der Konsten en Wetten- 
■scliappen,' Deel ii, quoted by De Wilde, 1. c, p. 426. 


rosacea), referring as it does to the perspiration, with, its 
pungent odour, which set in on the subsidence of the fever, 
and to the markedly favorable course of the disease in 
spite of symptoms often severe (pious people called it 
jnadosa or the " merciful ^^), leaves no doubt as to the 
nature of the sickness. For the years following, down to 
1824, there are only two accounts in medical writings which 
unquestionably refer to dengue. One of these is given by 
Leblond of an epidemic disease which prevailed at Santa F6 
de Bogota, the capital of Granada, towards the end of last 
century (three years before his ai'rival there) ; it occurred at 
the commencement of the rains, and few of the inhabitants of 
the city escaped it. He describes it in the following words : 
^' This malady began with headache, fever, and pains likes 
those of acute rheumatism, which led to its being mistaken 
at first for that disease ; but, after a few hours in bed, the 
crisis showed itself in the groin and testis of the male, or in 
the groin and lumbar region of the female, with congestion 
a,nd pain so severe as to draw loud cries from such of the 
patients as were over sensitive or had too little endurance. 
These congestions were soon dissipated by sweating.'^ The 
second account comes from Lima, where, according to the 
statements of Pezet, the disease was so generally prevalent 
during the summer (January and February) of 18 18, that 
out of 70,000 inhabitants in the city, only a few escaped 
having the sickness.'^ 

There can be no doubt that in these, as well as in many 
other parts of the globe which we shall mention imme- 
diately, the disease has been much more common and more 
widely spread in past centuries and down to recent times, 
than we have any knowledge of from the scanty epidemio- 
logical records. Thus Cavell and Mouat state that in India 
dengue had occurred under the name of " three days' fever " 
long before 1824, and that when it appeared in that year, many 
elderly people easily recognised it as an. old acquaintance. 
The accounts, also, of several medical authorities in Sene- 
gambia, Egypt, Arabia, and Oceania, speak of the disease as 
having occurred with comparative frequency in former times. 

^ This epidemic is mentioned (according to Smith) also by Paredes in the 
' Heraldode Lima,' 1854, No. 23-26. 


Not until the great epidemic of deugue Avhicli overran the 
West Indies and part of the North and South American 
continents in 1827 and 1828, was the attention of physicians 
drawn to the peculiar characters of the disease ; they learned 
to distinguish it from other diseases of the same class, with 
which it had often been confounded before, and thus the record 
of dengue, so far as historical research can make use of it, 
begins really with the third decade of the present century. 

Coming to that period, we meet with the first great epidemic 
of deugue in 1824 and 1825 in India and Further India. 
The scanty information available about it (Kennedy, Mellis, 
Twining, Mouat, Cavell, Robinson, Voigt) hardly enables 
us to say definitely how far it spread or what course it took. 
It broke out in May, 1824, simultaneously, as would seem, 
in the province of Gujerat and at Rangoon, somewhat later 
it was at Chittagong, and in Calcutta during the rainy 
season (July and August), whence it spread up the river by 
Chinsura, Serampore and Chandernagore, as far as Besham- 
pore. At the same time it was prevalent in Yanaon 
(mouth of the Godavery) and on the Coromandel coast 
(Madras and Pondicherry) . In March, 1825 it reappeared in 
Beshampoi'e, and extended thence during the rains along 
the valley of the Ganges to Channar, Patna, Ghazipore, 
Benares, and as far as Mirzapore. At the beginning of the 
cold season, the sickness disappeared at all these points, and 
so far as we learn from the data before us, it did not become 
general again until 1853 and 1854. "Whether the epidemic 
of dengue observed by Ehrenberg at Suez, in December, 
1824, had any connexion with the Indian one, cannot be 
ascertained in the absence of epidemiological records from 
Egypt for that period. 

During the next thirty years dengue appears to have been 
epidemic in the Eastern Hemisphere at scattered points only, 
as in 1835 on the Arabian coast {Primer); in June, July, 
and August, 1836, at Calcutta [Raleigh] ; at the same place 
in 1844 {Goodeve I) ; in August, 1845, at Cairo [Pruner) ; in 
1847 at Cawnpore [Goodeve II); in 1845 and 1848 in the 
French possessions of Goree and St. Louis in Senegambia 
[Rey] ; during the summer of 1851 in Reunion [Bidroulau, 
Ref. I, Cotholendij) ; and during the summer of 1852—53 


in Tahiti (Doutroulmi). In 1853 and 1854 dengue again 
became widely spread in Upper India, cliiefly in the Bengal 
Presidency, as appears from the published accounts {Goodeve 
11, Mackinnon, Sherif) ; according to Sheriff the disease 
was also prevalent at the time in Eangoon. This epidemic 
is succeeded by a series of local and circumscribed outbreaks 
as follow : in the French possessions in Senegambia fi-om 
June to August, 1856 [Boutroulan, Rey), and in June and 
July, 1S65 (Ref. I, Thahj) ; in 1856 at Benghazi, Tripoli 
[Pasqva), and in 1865, also in summer (July to September), 
in the Canary Islands (Ref. II, Poggio) ; further, in the 
summer (July to September) of 1867 at Cadiz {Poggio), 
and towards the end of the summer of 1868 at Port Said 

The history of dengue in the Eastern Hemisphere ends 
for the present with the great epidemic of 1870-73, in which 
the disease spread from the East African coast, over Arabia, 
Upper and Lower India, and as far as China. The first accounts 
of this outbreak date from Zanzibar, where the sickness 
appeared, according to Christie, in June, 1870, as a hitherto 
unknown malady, and continued until January, 187 1, not 
sparing the coast territory adjoining [Slierijf). Next to that 
in the order of time comes the epidemic outbreak of dengue 
in the summer and autumn of 1871 at Aden {Bead), Mecca, 
Medina, Jeddah, and other places on the Arabian coast 
(Ref. Ill, Buez, Sherif) ; the disease became epidemic anew 
there in the spring of the following year, and in Jed- 
dah again in 1873 {Bxiez). About the end of the summer of 
1 87 1, or shortly after it was at Aden, the sickness appeared 
at Port Said {Vmivray), and towards the end of the year 
(November) it broke out afc Bombay {Sheriff) and almost 
simultaneously in a filthy quarter of Calcutta {Raye). From 
these points the disease spread with great rapidity, but the 
proper epidemic diffusion did not take place there until the 
hot season. As early as January isolated cases occurred in 
Cananore {Sheriff] Ref. V, Fletcher, Sparrow), and Calicut; 
in the city of Madras the outbreak began early in February 
{Chipperfield, Sheriff^), cases were numerous in April, and the 
epidemic was at its height from August to October ; in Cal- 
cutta the disease grew to an epidemic in March and raged 


till June (Ref. YII, DunJclaj) ; at Poonah and Secundera- 
bad the first cases were in April ; at Cochin, Qailon {Mor- 
gan), and Yellorc in May, continuing in the last-named till 
October; and at Dacca {Wise) in June. The epidemic was 
at its height in Bengal from April to July (Ref. IV), and 
in the Presidencies of Madras (Ref, V) and Bombay 
(Ref. VI) from May to September ; its appearance was 
later in the North-West Provinces of Allahabad, Oude, and 
Merut, where it prevailed from June to December, spreading 
as far as Umballa and Lodiana on the Punjaul) frontier 
(Ref. IV). In the middle of April the sickness had 
reached Rangoon where it continued until July {Slaughter, 
Burnett) travelling to native Burmah somewhat later. It 
appeared at Shanghai in June, and at Amoy in August 
{Midler and Manson), whence it spread to places about ; 
it reached the Island of Formosa (Ref. IX, Galloway) in 
October, and in December it came to Java, where it was 
prevalent until March, 1873 {Be Wilde). In the year 
1873, dengue was again observed in many places in Upper 
and Lower India, especially in the Madras Presidency, and 
from March to October in Cochin China (il/on'ce, Breton). 
The last offshoots of this great epidemic were the outbreaks 
on the Islands of Mauritius and Reunion, which occurred 
respectively in January and February, 1873, and died out in 
May {Bralievridge, Cotholendy). Since the close of that out- 
break the disease has been epidemic only once, as far as is 
known, in the Eastern Hemisphere — in 1878 at the port of 
Benghazi in Tripoli ; according to the account of Pasqua the 
first cases occurred in the beginning of October ; the disease 
assumed an epidemic character towards the end of the month, 
and spread through the greater part of the population, but 
it beg-an to decline as earlv as the beginning of November, 
and by the end of that month it had died out completely. 

In the Western Hemisphere, during the period subse- 
quent to 1824, we meet first Avith an epidemic of dengue at 
Savannah, Ga., in the autumn (August to October) of 1826 
{Baniell, Wao-ing) ; this was followed by a long train of sickness 
in the next two years, extendiug over the whole West Indies 
and a great part of the Southern States of the Union, and not 
sparing even the northern parts of the South American coast. 


This great epidemic started from three points : the Virgin 
Islands, St. Thomas, where it was prevalent from Sep- 
tember, 1827, to January, 1828 {Stedman, Lilders), and 
Santa Cruz, where it broke out in October, 1827, and lasted 
till March, 182S {Stedman, liuan). From these centres it 
extended continuously in a southerly and westerly direction 
over the Lesser and Greater Antilles. Thus it prevailed on 
St. Bartholomew from November, 1827 until January, 1828 
[GocJc], on St Kitts from December to April [Squaer), on 
Antigua from January to March {NicJiohon, Furlonge), on 
Gaudeloupo and Martinique from January to June {Moreau de 
Jonnes) ; on Bai'badoes it broke out in March, and on Tabago,. 
the most southern of the Lesser Antilles, it appeared in May,. 
1828. In the westerly direction it came to Jamaica in 
December, 1827 [Maxivell, Stennet), and to Cuba-^ in March,. 
1828 {Tuite, Osgood). On the Island of Curasao, lying off the 
Venezuelan coast, the disease is said to have appeared as 
early as November, 1827; of its prevalence elsewhere in 
South America there are accounts only from the State of 
New Granada, from Carthagena (Ref. X), and from 
Bogota {Waterson). On the continent of North America the 
disease showed itself first at Pensacola, Flor., in the spring 
of 1828 (Ref. X) ; it appeared at Charleston {DicJcson I) 
and New Orleans {Bumarescq) in June, at Savannah, Ga., in 
August [Daniell, Waring), and it reached Vera Cruz, Mexico, 
a little later {Barrington). Whether it attained a wider dif- 
fusion in Mexico is questionable. The Northern and Central 
States, as well as the interior of the United States, remained 
quite exempt from this epidemic, a few cases having been 
observed only at Philadelphia, among the crew of a vessel 
arrived from Havana {Lehmann). On the other hand, the 
disease was epidemic in the autumn of 1828 in the Bermudas 

For the next twenty years there are only a few trust- 
worthy notices of epidemics of dengue in the Western 
Hemisphere.- These are for the Bermudas in 1837, for Rio de 

' There is no information as to the occuiTence o£ dengue in this epidemic 
on Porto Eico and Domingo. 

" It seems to me to be very doubtful whether the disease observed by 
Hildreth (' Amer. Journ. of Med Sc, 1830, Feb., p. 330) at Marietta, Ohio, 


Janeiro in 1845— 1849 ^^^^ disease having been prevalent firstly 
from December, 1845, ^^ August, 1846 {Lallemant II), tlien 
from October, 1846, to March, 1847 {Bollinger, Lallonant I, 
II), and again during the summers of 1848 and 1849 {Lalle- 
nnant II), and finally for New Orleans in the autumn of 1849 

In 1850 dengue again became widely diffused over the 
Southern States of the Union. It first appeared in July at 
Charleston [Wragg, Dickson II), in August simultaneously at 
Savannah {Arnold II), Augusta {Camphell) and New Orleans 
{Fenner) ; in September at Mobile (Anderson 1), and Wood- 
ville, Miss. (Holt) ; and, finally, in October at Galveston, 
Texas, whence it spread along the coast by Matagorda and 
Lavacca as far as Fort Brown {Jarvis). The accounts that 
have come to hand of dengue in the Western Hemisphere 
since the subsidence of that outbreak point to more scattered 
epidemic occurrences of the disease. There was an outbreak 
at Callao and Lima {Smith) in the summer and autumn of 
1 85 1 (December to July), it prevailed at Mobile during the 
autumn of 1854 {Ketchum) as well as in Cuba and other 
West Indian Islands {Arholeya), in Martinique {Ballot), in 
the summer and autumn of i860 (June to December) and in 
the Bermudas {Smart), where the disease recurred at the 
^ame time of the year in 1863. The latest information 
dates from 1873, and relates to epidemics of dengue in Ala- 
bama {Anderson II), at Vicksburg, Miss. (Ref. XI), and 
at Port Hudson and other places in Eastern Louisiana 
{Marsh) . 

There can be hardly any doubt that this survey of the 
epidemics of dengue hitherto known is not one that gives a com- 
plete outline of the diffusion of the disease in time and place, and 
that it is wanting in accurate information both as to the time of 
its first appearance at the various places, and as to the places 
where it has something of the character of an endemic malady. 
As I'egards the occurrence of dengue in Egjq^t, it was long 
ago stated by Ehrenberg that the disease was not rare there, 
and that it had been still more frequently observed in Arabia, 

in the spring of 1829, was really dengixe. I am unable to form an opinion as 
to the character of the epidemic which was prevalent, according to newspaper 
reports, at Iberville, La., in November, 1839. 


especially in Jeddali and Jambo^; and tliis statement is 
confirmed for Arabia by Sheriff, and for Egypt by Vauvray, 
Avho remarks tliat deng-ue is common in that country at the 
time of the date-gathering, and is therefore known under 
the name of " fievre des dattes/^ Rey mentions that 
in the period from 1847 ^o 1856, "^ery few years passed 
without the disease showing itself in Tahiti, and that it had 
occurred also on board vessels at anchor in the harbour of 
Papite. In the Hawaiian Islands the malady appears to 
be not uncommon ; the disease known to Duplouy under 
the name of " bonon '^ (sighs) as occurring there especially 
at the rainy season, may undoubtedly be set down as 
dengue. That it occurred in India before 1824 follows from 
the account of Cavell for Calcutta, where the disease used 
to be called '^ three-days^ fever,'^ and from the statement of 
Mouat that the disease had been observed at Beshampore on 
previous occasions, if not in such wide diffusion. Thaly 
remarks that it is prevalent in Senegambia, '' sous le forme 
endemo-epidemique,'' and Yerdier^also mentions its frequent 
occurrence there.^ To the same effect is the statement of 
Smart, with reference to the Bermudas, that sporadic cases 
are observed every year there, and that the disease gr-ows to 
an epidemic from time to time. It is said also by Hamilton 
to be a not uncommon malady in Honduras. 

At other places, again, the disease appears to have occurrred 
for the first time at a later date, or even quite recently, 
and to have been less frequently prevalent ; thus, as Wise 
points out, it had never been observed prior to 1872 in the 
district of Dacca (Presidency of Bengal), nor, according to 
Sheriff, in the Presidency of Bombay, or in the City of 
Madras. The same is true for Amoy, according to Mliller and 
Manson, and according to Christie for the East Coast of 
Africa, where the disease was quite unknown previous to 
the outbreak in 1871. In Reunion and Mauritius dengue 
became prevalent for the first time in 1851, according to 

^ He mentions that his travelling companion Hempiich had the dengue 
sickness on the Arabian coast. 

= L. c, p. 53. 

3 It is a significant fact that the natives of Senegambia have a popular 
name for dengue, n'dagamonte or n'rogni. 



the corroborative statements of Cotliolendy and Brakenridge. 
This applies with even greater force to the outbreaks of the 
disease that have happened in recent times in the Western 
Hemisphere. Fnrlonge, Moreau de JonneSj and almost all 
the chroniclers of the dengue epidemic of the West Indies in 
1827 and 1828 declare that the disease had never occurred 
there pi*evious to that time. The case is the same_, according 
to Dollingcr^ for Brazil^ where the disease showed itself for 
the first time in 1 845 and 1 846. In the United States, also, 
dengue is counted among the diseases that are only rarely 
met with.^ 

§ 14. Characteristics of Dengue as an Epidemic. 

Before considering the question of the influence exerted 
upon the occurrence and diffusion of dengue by climate, 
weather, soil, and other factors in the environment of the 
individual, as well as by circumstances of race, age, and sex, 
I shall direct attention to some peculiarities in the form and 
tyi'>e of its epidemics. Their sudden outbreak and their 
rapid diifusion, usually over the greater part of the popula- 
tion of the affected locality, afford a striking analogy ^Yith the 
phenomena observed in epidemics of influenza. Numerous 
authorities lay the greatest stress on these circumstances, 
which are not without significance in forming our opinion of 
the origin of the disease. 

In the epidemic of dengue at Lima in 1S18, only a few out 
of the whole 70,000 inhabitants of the city escaped having the 
sickness. In a postscript to Mouat's report of the Besham- 
pore epidemic of 1825, it is stated": ^' At Churuarghur and 
in its immediate vicinity not fewer than 10,000 natives are 
said to have suffered from the disease at one period ; " and 
Robinson says that hardly one man remained well in the 

* In the 'Transact, of tlie Amer. Med. Assoc.,' 1851, iv, the ei^idemic 
of 1850111 the Southern States is referred to as follows: "This epidemic 

is rare in its occurrence Since its former appearance in 1828 

no analogous epidemic disease has prevailed to any great extent until the 
past summer." 

2 L. c, p. 49. 


European regiment stationed at Ghazipoor during the preva- 
lence of the same epidemic. In Stedman's report on the 
epidemic of 1827 in St. Thomas, we i-ead : "The disease 
suddenly made its appearance in the island and attacked 
almost every individual in the town, which contains a popu- 
lation of about 12,000 souls. . . . The disease appeax'ed 
suddenly and spread with rapidity. . . . Not a day 
passed but hundreds were attacked, and of this the conse- 
quence was a great intei'ruption to trade.'" In Antigua, 
according to Nicholson, dengue prevailed to such an extent 
" that very few of the inhabitants of this town escaped its 
attack." Maxwell, for Jamaica,^ speaks of the " rapid 
manner in which this singular . . . disease spread," 
and adds : — " There probably never was a more general epi- 
demic than this. . . . Almost the whole white and 
coloured population were sooner or later affected, and very 
few remained who were not personally acquainted with the 
dandy fever." In his account of the epidemic in Martinique, 
Moreau de Jonnes says : '' An official document affij-ms that 
one half of the inhabitants of Havana were attacked by it 
almost simultaneously, and it became necessary to erect 
temporary hospitals in several quarters of the city •/' and 
Osgood caps this statement with the declaration that, in 
its further course, the epidemic extended to almost the 
whole population of the city. The " universality of the 
attack," and " its sudden appearance and rapid course," are 
specially emphasised as chai'acteristic of the spread of the 
epidemic of 1828 in the Southern States of the Union.^ 
Dickson begins his report upon this epidemic in Charleston 
with the words: "About the end of June, 1828, a singular 
disease made its appearance in our city, through which it 
spread with unexampled rapidity, soon bringing imder its 
influence the greater part of our population." And Duma- 
rescq writes to the same effect of the outbi-eak and progress 
of the sickness at that time in New Orleans. In Lallemant's 
(II) account of the epidemic of dengue at Rio de Janeiro 
in the summer of 1846-47, he says :^ — "The quickness 

' L. c, p. 151. 

- ' Statist. Eeport on the Sickness and Mortality in tlie Ai-my of the U. S. 
for the years 1821 to 1839,' Washington, 1840, p. 6^. 

' L. c, p. 506. 


■with which the disease spread was indeed most remark- 
able. . , . The sickness broke out almost simul- 
taneously in the provincial capital of Eaya Grande^ opposite 
our capital, on the other side of the bay. On the haciende, 
in the neighbourhood, whole gangs of negroes fell ill, whik- 
in the various mercantile houses there were none of the 
principals and not always a half-crippled clerk to be found 
often for a whole week long. Ships were delayed in 
loading and unable to get to sea, and even the schools 
were deserted.'^ Of the epidemic of 1851 in Keunion it is 
said :^ — "It spread so rapidly that the hospitals were 
crowded in a few days;" and of the 1873 epidemic in the 
same colony, Cotholendy states that out of 35,000 inha- 
bitants of the town of St. Denis there must have been some' 
20,000 taken ill. In Mauritius during that epidemic, accord- 
ing to Brackenridge, only a few of the population quite 
escaped the sickness. In the epidemic of 1871—72 at Cal- 
cutta, the number of cases was estimated at 75 per cent, of 
the population -^ at many places in the Madras Presidency, 
where the disease was prevalent at the same time, scai-cely one 
person remained well, and in the City of Madras hardly a 
house escaped {Sherif) . In Zanzibar, Christie says that almost 
the whole population sickened. In Rangoon {Burnett) at 
least two thirds of the inhabitants suffered in 1872, and the 
proportion was similar in the epidemic of the same year in 
Formosa [Galloway). 

§ 15. A Disease op the Tropics and of Hot Seasons. 

Tlie area of diffusion of dengue, so far as it has become 
known to us hitherto, extends from 32° 47' North latitude 
(Charleston in South Carolina, and Lodiana in India), to 
23° 23' S. (San Paulo in Brazil), unless, indeed, we stretch it 
so as to include the occasional outbreaks in Philadelphia 
(39° 5^' ^•)} ^^^ o^^ ^^6 south coast of Spain (36° 10' N.). 
The disease has therefore the character of a highhj tropicaif 
malady, and in that respect, as well as in its inroads into> 

' Dutroulaii, 1. c, p. 89. 

^ 'Lancet,' 1872, June 8tli, p. 811. 


higlier latitudes, it corresponds to yellow fever, altliougli the 
latter extends in tlie Soutliern Hemispliere to 34° 46 ' 
(Buenos Ayres). 

The conclusion which may be drawn from tliis, tliat the 
origin of tlie disease depends upon atmospheric influences 
proper to the climate, particularly the temperature, finds 
support in the behaviour of the epidemic in regard to 
seasons and weather. Summer and the early autumn is the 
proper dengue season, as the dates already given will show. 
This is particularly true of those regions not strictly tropical, 
where the disease appears almost regularly in July and 
August, seldom so late as September, and always with 
unusually high temperature ; even in the tropics most of 
the epidemics have happened in summer, or at least have 
attained their widest prevalence at that season. It is signi- 
ficant of the degree to which this association of dengue with 
certain seasonal influences has impressed observers, that many 
of them would make weather characterised hy high temperatiwe 
an essential condition for the prevalence of the disease.^ But 
above all there is the considei'ation that a great fall in the 
temperature, or the setting in of absolutely cold weather, 
brings the epidemic of dengue to an end, just as it does 
in the case of yellow fever. 

In the Philadelphia epidemic of 1780 the disease declined 
so much in the beginning of October, on the setting in of 
cold weather, with rain and rough east winds, that only a case 
here and there came under observation (Rush). Referring 
to the course of the sickness at Savannah in 1826, Waring 
says :^ "During the winter of 1826-27, the break-bone 

^ Cotholendy (1. c, p. 194) gives tlie following interesting fact relating 
"to this point from the Reunion epidemic of 1872 : — " The colony possesses 
•at Salazie a mineral spring situated at a height of about 900 metres among 
the mountains occupying the centre of the island. Despite the con- 
.siderable stir among travellers and sick people who left St. Denis to 
go to the spa during the epidemic, the disease at the latter attacked only 
two persons, who had acquired the germs of it at St. Denis. It had no 
power to propagate itself." The same thing was observed at Brule, 
situated 700 to Soo metres above St. Denis. The author is doubtless right 
in referring the exemption of that place to the relatively cold climate proper 
io its elevated situation. 

2 L. c, p. 375. 


fever has been suppressed by tlie frost," and of the epidemic 
of 1828 he says^ that it "terminated under the effect of 
frost/' The epidemic of 1872 at Madi*as ended in the 
middle of October after heavy rains and cold weather had 
set in (Sheriff) ; and, in like manner, in the epidemic of that 
year in the North-West Provinces, only occasional cases 
occurred from October onwards. In Savannah the sickness 
of 1850 died out in the same way on the setting in of frost ; 
Arnold (II), who mentions that fact, sums up the experience- 
derived from all places in the United States that had been 
visited by dengue : " This disease is undoubtedly affected 
by frost ; the diminution of cases after a frost last fall was 
as marked as the diminution of cases in our endemic climate 
fever {i.e. yellow fever) usually is/^ 

There has been an apparent exception to this in the 
occurrence of dengue during damp and cool weather in 1827- 
28 in several of the West India Islands, particularly St. Kitts, 
Antigua, St. Bartholomew, Jamaica, and Cura9ao. " The 
Aveather,'' says Squaer,^ " previous to the appearance under 
consideration, and during its continuance, was of a nature 
unprecedented in severity in the West Indies, at least for 
very many years. In the latter end of November, and nearly 
up to the present period (April, 1828), the weather became 
extremely boisterous, being nothing but a continuance of heavy 
rains and high winds ; the evenings were cold, very cold for 
this country, so much so that we were obliged to shut our 
doors and windows on sitting down to dinner, and we found 
it requisite to cover ourselves with a blanket at night.'* 
Stennett's account for Jamaica is to the same effect, although 
it would appear that it was not there a matter of actually 
cold weather, but only of a relatively cool temperature, to 
which the inhabitants of those regions must have been 
particularly susceptible, for Stennett gives the morning 
reading of the thermometer (or the minimum) at or about 
64° F. But at any rate the fact is important as bearing on 
the question how far the production of the disease is depen- 
dent on the warmth of the air. 

The amo^mt of moisture in the air is less decisive of the 
prevalence of dengue than the temperature, and is probably 
' L. c, p. 391. - L. c, p. 25. 


indeed, Avithout significance ; at least, the disease has broken 
out and run an epidemic course just as often during pro- 
longed dryness of the air as during heavy rains. Examples 
of the latter are found in the epidemics of 1827—28 
just mentioned, in several of the West India Islands, and 
further, in the epidemics in Reunion, Tahiti, Senegambia, 
and in that of i860 in Martinique. On the other hand, the 
disease was prevalent at a time of absolute drought in 1780 
at Philadelphia, in 1824 in Goojerat, in 1827 on St. Thomas — 
the first of the Antilles to be attacked on that occasion — in 
1828 at Havana {Tuite), Savannah [Waring), Charleston 
(Dickson I), and Vera Cruz {Stedman, Barrington) ; further, 
in 1836 at Calcutta {Raleigh), in 1850 at Woodville, Tenn. 
(Holt), Augusta, Ga. {Cavvpbell), Charleston {DicJcson II), and 
other places in the United States,^ and in 1872 at Madras 

§ 16. Influence op Locality. 

Notwithstanding the lively interest which the disease has 
excited among medical observers at all the places where it 
occurs, the question of the influence exerted by circumstances 
of locality on the production of the morbid condition has been 
little adverted to ; it has not been discussed from any side 
with the thoroughness to be wished, and consequently the 
information to be got from the epidemiological records before 
us is too scanty to suffice for even an approximate solution of 
this question. 

The first noteworthy circumstance is that the area of 
distribution of the disease in the Western Hemisphere has 
been almost limited to places on the coast. The data 
before us on this point from the West Indian epidemic of 
1827-28 are very precise. "The denguo,^^ says Osgood, 
" has not spread into the interior of Cuba, although at the end 
of five months from the time of its rise in Havana, it con- 

1 In the General Report (xii) on the dengue epidemic of 1850 in the 
Southern States it is stated : " Long-continued dry and hot weather pre- 
ceded the development of the epidemic in all the places in which it has been 



tinues to attack most of the persons wlio come to tlie city 
from the country or from any place (of the interior) where it 
has not prevailed.'^ Stennet makes a similar observation 
for Jamaica: "It has passed nil over the island, chiefly, 
however, prevailing in the towns along the sea shore/' Also 
in the later epidemics in the AVest Indies — in Cuba, Mar- 
tinique and other islands — it is always the occurrence of the 
disease in the coast towns that is spoken of, and there is 
never any mention of its further epidemic extension into the 
interior. This fact in the distribution of the disease comes 
out also very prominently in the Southern States of the 
Union, where dengue has been prevalent almost exclusively 
on the coast, although it spreads along the Mississippi as far 
up as Vicksburg. In Brazil and Peru also, so far as we 
know, it has been strictly limited to the coast. The 
same is true of the outbreaks of dengue on the east and 
west coasts of Africa, on the coast of Arabia, and elsewhere ; 
and even in the isolated outbreaks of the disease in Spain, 
it has always been a few coast places that have suffered, 
without transmitting the sickness into the interior. 

A second fact showing the influence of locality on the 
production and diffusion of dengue is found in the limitation 
of the disease, as an epidemic, for the most part to towns ; 
in which respect also it has an aSinity with yellow fever. In 
the report (XII) on the 1850 epidemic in the United States, 
it is expi'essly mentioned that, excepting in New Iberia, La., 
towns only were affected ; in the West Indies also, as 
we have seen, it was almost exclusively in towns situated 
on the coast that the disease occurred in epidemic form. I 
reserve other observations relating to the point until I come 
to the question of the communicability of dengue. A natural 
explanation of the fact readily suggests itself in the cramped 
and crowded life of urban populations and the hygienic abuses 
inevitably associated therewith, presenting a particularly 
favorable soil for this as for other morbid poisons to develop 
in. De Wilde, in his account of the dengue epidemic that 
occurred in 1872 among the garrison of Fort Willem I in 
Java, points out that the disease mostly attacked the occu- 
pants of two block-houses occupying a particularly unhealthy 
site, and attacked them, too, without distinction of race. 


Tank, sex, or age ; those individuals, on the other hand, who 
■were housed under more favorable conditions, enjoyed a 
striking exemption ; and he adds : " There need be no 
hesitation in assuming that the unhealthiness of the houses 
•was the immediate cause of their selection/^ In the Calcutta 
epidemic of 1871-72, the disease was first developed among 
the Jews occupying the poorest and most densely populated 
parts of the city (Eef. VII). Smart is of opinion that crowded 
rooms and the ^tween decks of ships are the favourite seats of 
the disease, and the most intense foci of sickness. In the 
Philadelphia epidemic of 1780, dengue was most prevalent 
in the streets along the Delaware shore, filthy, overcrowded, 
and occupied by the poor, while those situated at some 
distance from the river were only slightly affected. At 
St. Denis (Reunion), according to Cctholendy, the over- 
populated parts of the town, with the houses crowded close 
together, were the chief seat of the disease, while those 
houses of the town proper, situated within gardens, and 
therefore separated from the adjoining buildings, suffered 
from the sickness only here and there, but they suffered 
throughout the whole household when once attacked. In 
many other instances, however, the epidemic has spread 
uniformly over the whole of a town. 

§ 17. Slight Influence of Race, etc. 

An almost absolute independence of the circumstances of 
■race, nationality, age, and sex may be recognised in the dis- 
tribution of the disease at all times and in every place. 
'Only a few observers, such as Squaer, Maxwell, and Sted- 
man in the West Indian epidemic of 1827, have found that 
the negroes had the sickness more rarely or more mildly. 
In the Java epidemic of 1872, according to De "Wilde, that 
race enjoyed an almost complete immunity. In like manner 
Pasqua says of the epidemic at Benghazi : " It was notable 
for the remarkable immunity experienced by the blacks ;" but 
he adds that this race at the same time had no exemption 
in Egypt, Senegal, and elsewhere. Christie, also, is of 
opinion that the natives of Zanzibar suffered less than the 


Europeans. On the other hand, Kennedy, in Goojerat, 1824, 
and Manson and Milller at Anioy, 1872, met with more 
numerous and more severe cases among the natives than 
among the Europeans. In Cochin China, according to 
Breton, cases of sickness were much more frequent among 
the Anamese part of the population than among the Chiuese. 
Wise, in the Dacca epidemic of 1872, appears to have found 
a peculiar predisposition to dengue sickness in persons suffer- 
ing from surgical complaints. According to Brackenridge, 
children enjoyed a certain immunity in the Mauritius epi- 
demic of 1873. It must remain an open question how far all 
these isolated data may be trusted ; at all events, differences 
of that kind in the liability to sickness in a mixed population 
are only rare exceptions to the general rule above stated. 

§ 18. Specific Character : Question of its CoiiMUNiCABiLiTY. 

As to the specific iiature of dengue there can be no reason- 
able doubt. All observers take the malady to be an infective 
disease (although they may express this idea in different 
ways), with a specific cause, underlying which is a morbid 
poison. The origin and nature of this poison^ is enveloped, 
however, in the same obscurity that hangs around the virus 
of every other acute infective disease ; we can only say 
this much of it with certainty, that its activity (perhaps also 
its production) is materially under the influence of high tem- 
perature, that its manifestations point to a certain connexion 
with the sea coasts and the shores of great rivers, and that 
it appears to attain its widest diffusion where the population is 
densest. Whether this poison springs up de novo at all points 
where its potency is manifested ; whether it is endemic only at 
a few places and spreads from these under favouring circum- 
stances, so giving rise to the more general prevalence of the 

^ This is another of those diseases in which there has naturally been no 
lack of conjecture as to the parasitic nature of tlie morbid poison. Thus, 
Dickson (II) and Poggio make it out to be a living germ ; and Charles, on 
examining the blood o£ dengue patients, found therein, especially from the 
third to the sixth day, small round corpuscles which he takes to be organic 
elements, and to which he appears disposed to assign some specific importance 
in the morbid process. 


disease ; what are the ways or the media by which this diffu- 
sion is effected — all these questions and others connected 
with them cannot be auswei-ed with certainty in the present 
state of our knowledge. At the first general outbreak o£ 
dengue in India in 1824^ and in the West Indies and United 
States in 1827-28, the belief in the communicability or 
contagiousness of the disease found only a few adherents.^ 
During the next forty years, while the disease was getting 
more and more limited in its area and becominsr all the 
more adapted therefore to furnish the data for a conclusion 
as to its true mode of spreading, there were still only a 
few observers who pronounced decidedly for its contagious 
character. It was not until the great dengue epidemic of 
1871-73, in the tropical regions of the Eastern Hemisphere, 
that a change of opinion was effected ; the position of the 
anti-contagionists was practically abandoned, and the disease 
was recognised to be "^ in the highest degree contagious." 

The proof that the disease originates by way of communi- 
cation rests on the fact of its having been observed to break 
out directly after sick persons from an infected locality have 
arrived at places that had been up to that time healthy ; so 
that the diffusion of the disease could be traced, more 
especially in the epidemic of 1871—73 in the East, from 
port to port, and from country to country, along the 
highways of land or water traffic, as if step by step. The 
affirmative answer on the question of contagiousness derives 
additional support from the often observed fact, that the 
outbreak of the sickness takes place in the immediate 

' Among tlie physicians in India who observed the 1824 epidemic and the 
subsequent isolated outbreaks of the disease at Calcutta, Cawnpore, and 
other places, there was not one who declared for its contagiousness ; so that 
Jackson is right in saying (1. c, p. 208) : " It is strange that in the 
epidemic of 1S24 in Calcutta [and other pai-ts of India] almost all the 
medical men of the day believed that the disease was not communicated 
from man to man, whilst the reverse is the case in the late epidemic 
(1871-72), the supporters of the non-contagious theory being in a very 
decided minority." Among the West Indian physicians only Stedman and 
Cock came forward as decided adherents of the theory of contagiousness, and 
Dickson was its only supporter in the United States. In 1850, Dickson still 
remained true to that opinion, as against Wragg, Arnold, and various others 
who pronounced decidedly against the contagiousness of dengue. 


vicinity of the first patients, tliat new foci of sickness 
form around that point, the disease thus spreading through 
families, houses, and streets, that those persons who have 
come oftenest into direct contact with the sick (such as 
relatives, medical attendants, and nurses) become victims 
of the epidemic most surely and most speedily, and that 
isolation of the sick or avoidance of intercourse with them 
ensures protection from the disease. 

However striking many of the accepted observations in 
iavour of the communicability of dengue may seem at the first 
glance, we should not be justified, on an impartial examina- 
tion of them, in taking them all as equally good evidence ; 
and if criticism can of itself shake the belief in the " eminent 
contagiousness ■" of the disease, there are additional facts, 
overlooked by the partisans of the doctrine of contagious- 
ness, which should weigh in the scale no less. I shall limit 
myself to a discussion of the more important of these facts, 
after first directing attention to the absence of critical caution 
in tracing the outbreaks at particular localities to the 
arrival of ships or to movements on land, and therein finding 
the explanation. 

While Cock^ considered it proved that the sickness of 1827 
was imported into St. Kitts by a ship from St. Bartholo- 
mew, Squaer, who was an eye witness of the epidemic on the 
island, says r " It is not meant that the present disease 
should be considered as having been brought to this 
island by means of communication. '^ Waterson also^ speaks 
decidedly in favour of the de novo origin of the disease on 
that occasion. The outbreak of the disease at Havana in 
1828 was traced to the arrival of a Spanish flotilla which came 
from the South American coast, having touched at Cura9ao 
where dengue was epidemic ; but Robert observes -^ ^' It is 
right, however, to state that before the arrival of Admiral 
Laborde at Havana, there was a disease almost of the same 
nature in the port of Santiago de Cuba, where the crew and 
troops on board the Spanish frigate * Aretuza ' were attacked." 
In the account of the epidemic of 1850 in New Iberia, La., 
the outbreak was traced to a person who came from New 
Orleans and took the disease shortly after he arrived ; " but," 
' L. c, p. 46. " L. c, p. 22. ^ L. c, p. 309. ■• L. c, p. 315. ^ 


says the chronicler, " there was no connexion between the 
first and second cases, the subject of the first being a 
strangrer, whom no one but his medical attendant had visited. 
Again, persons from the country who visited 
our village and remained any length of time on business or 
to nurse the sick, took the disease on their return home, but 
in no instance did it spread among the other members of 
the family/^ Yauvray thought that the dengue epidemic of 
1 87 1 at Port Said should be attributed to importation from 
Aden, but how far he was right will appear from the words 
added by himself: ''I ought to mention, at the same time, that 
the dengue fever was epidemic in 1868, and according to my 
civilian colleagues there have been some sporadic cases of it 
every year towards autumn. If it be an endemic malady, it 
must still be admitted that at certain junctures it takes on 
an epidemic character.^^ The outbreak at Lima in 1852 was 
thought to be connected either with importation of Chinese or 
with German immigrants from Rio. The former assumption 
is said by Smith, who has written on the subject, to be quite 
untenable ; the latter he looks on as better grounded, but 
the description which he gives of the disease observed by 
himself among the Germans, shows that these unfortunates 
had suffered not from dengue but from severe forms of 

Nothing, in my opinion, tells so little in favour of, and so 
much against contagiousness, as the sudden and simultaneous 
appearance of the disease over a great part of the population, 
an observation that has been made at the most diverse points 
of the wide area covered by dengue. The facts already men- 
tioned at the beginning of this inquiry are borne out by others 
of the same kind : " In New Orleans," says Dumarescq refer- 
ring to tbe epidemic of 1828, '^the disease was not propagated 
by contagion ; four persons were attacked by it at the same 
time, and its spread was so rapid among the inhabitants that 

1 [A perusal of Dr. Smith's papers bears out the impression of Professor 
Hirsch, stated elsewhere, that it was not yellow fever that the German 
immigrants suffered from. At the same time the symptoms described 
by Dr. Smith correspond closely to those of dengue. The assertion that the 
ships conveying the emigrants from Bremen had touched at Eio on the 
way to Peru has not been substantiated. See Smith, ' Epidemiol. Trans.,' i^ 
p. 286.] 


in eight or ten days at least one third of the population was 
labouring under its influence." Twining says of the spread 
of the disease at Calcutta in 1824: "I do not know that 
any proof can be adduced of the contagious nature of this 
disease : on the contrary, I believe it was not communicable 
from one person to another, because it arose at the same 
time in remote parts of the town, and affected persons who 
had not had any communication with sick people. Its pro- 
gress was not that slow and gradual march which depends on 
personal communication and can often be traced." Wragg 
thus sums up his experiences of the Charleston epidemic of 
1850, which completely agree with the observations made 
there by Dickson in the epidemic of 1828 (see p. 67): 
*' I do not think it contagious, because its invasion was so 
sudden and general all over the city, that any attempt to 
trace it from patient to patient, from house to house, or from 
quarter to quarter would utterly fail." 

In this peculiarity of its epidemic behaviour, dengue con- 
nects in the most obvious way with influenza ; and if the facts 
concerning influenza are such as to furnish a real argument 
against its contagiousness, we may take up the same critical 
attitude towards dengue. A second analogy between those 
two diseases lies in the fact that at the time of dengue 
epidemics, just as during epidemics of influenza, there have 
been noticed cases of animal sickness with more or less 
distinctly typical marks of dengue. Observations of that 
kind are reported by Cubillas from the epidemic of 1784 at 
Cadiz, by Martialis, based on reports in the Indian papers 
('Friend of India,' &c.) from the 1872 epidemic at Baroda, 
-where it was chiefly the cattle that suffered, and by Slaughter 
for the epidemic of the same year at Rangoon, where the 
victims were mostly dogs and cats. 

There is a third argument against the '' eminently con- 
tagious " character of dengue, namely, the somewhat narrow 
limits of the epidemic as observed in many instances, or the 
association of it with definite local conditions, beyond which 
the disease has not penetrated notwithstanding importations 
on a large scale. "Waring concludes his description of the 
Savannah epidemic of 1828 with the remark : '^ Xot one case 
is known to have originated upon the plantations, and 

rEfrrrm. 79 

c'-'-z'^'a. some persons, after iiaving :::':' ..1 :'.:" '-:•? 
gernisj, went inco the ccantry, it is n^- ■-■ - - - -' - -' j 
^ '•"" ■ j-^ "-?d them in a single instance. ^ - . - .' 

argnment, it appears to me, a^-_-_;: :_. :.. - 'j. 

• :' :•: - :.\rion or importation/^ To the same effect is Osgood's 
is we have seen, on the immnnity enjoyed by the 
int . while dengue was prevalent at Havana and 

ot: -, and despite the conveyance inland of 

many ca.- - . irase. Against contagiousness, Wragg 

adduces as vviiiciice the fe.ct that the epidemic of 1S50 was 

~ ^"^- ■ ■ "" "" ~ ■ " •■"":• neighbourhood of Charleston, and 

_ ; : ~, " although the city was thronged 

with J.. ;._:.. ._ .-i^s of the neighbouring country on 

business T . . ,"? several instances in which, after 

the greatest possible e:.- . - .re, the disease was not developed." 
Pasqua also states that the epidemic of 1878 at Benghazi was 
not imported but ' '. : , . - ^^ia there, and 

that it was strictly cc- - . not a single case 

having occurred ■ - \ . - . 

In view of thci _■ : : 5, we slutll have to treat 

the question of the c. -_ ,; t,_-_.. ,. ^^^ ^-^^ p^.^^ 

sent as an open one. .^.-^ .: ■•-- • --/ necessary to 

withhold an opinion as to whert . is indiqeniyus 

and where it is merely intnoduced. This caution of criticism 
is all the more required, inasmuch as the area of diffusion of 
the sickness up to the present, as well as the epidemiological 
history, have been made known to us only in scanty outlines. 
If, in forming an opinion as to eudemicity, we were to 
assume that every place within the dengue area was an 
endemic focus because the disease had broken out there 
once or oftener when there was no proof of importation, then 
there wotild be hardly any" locality left to exclude from the 
list of endemic centres. 


AitdesnoB (I) in Proceedings of the State Med. Sdc. of AklauBa, 1851. 
AaiezaoBi (D), ib., 1S74- Arfeoleya, Historia de tma ejrid. fadecida en 
Ciiraaao j la Habaaa, ddiz, 1834. Arnold (I), Chariestoa MedL Joontal 
1849, Jul J. AxBMiId (11)*, ib., 1831, May, 333. 


Ballot, Arch, de mcd. nav., 1S70, xiii, 470. Barrington, Amer. Journ, 
of Med. Sc, 1833, Aug., 307. Brakenridge in Edinb. Med. Journ., 1874, 
Oct., 322. Breton, Considerations sur la guerison des plaies cliirur- 
gicales . . chez les Annaraites, Par. 1876, 10. Buez, Gaz. des hopit., 
1873, 501. Burnett, Brit. Navy Eeport for 1872, 210. 

Campbell, Southern IMed. Journ., 1850, Nov. Castilla, Descripcion de 
la epidemia llamada influenza, etc. Cadix, 17*^9. Cavell, Calcutta Med. 
Transact., ii, 33. Charles, Eighth Annual Report of the Sanitary Com- 
mission . . of* India, 112. Chipperfield in Madras Quart. Journ. of 
Med. Sc, 1872, V, 277. Christie, Brit. Med. Journ., 1872, June i, 577. 
Cock, Edinb. Med. and Surg. Journ., 1830, Jan., 43. Cotholendy in Arch, 
de med. nav., 1873, xx, 190. Cubillas, Epidemia Gaditana nombrada la 
piadosa, etc. Cadix, s. a. 

Daniell in Amer. Journ. of Med. Sc, 1829, Aug., 291. Dickson (I) ib., 

1828, Nov. 3, and 1829, May, 62. Dickson (II), Charleston Med. Journ., 
1850, Oct. Dollinger in Bayr. Med. Intelligenzbl., 1858, 264. Dumarescq, 
Boston Med. and Surg. Journ., 1838, i, Nr. 32, 495. Dunkley, Brit. Med. 
Joum., 1872, Oct. 5, 378. Duplouy, Arch, de med. nav., 1864, ii, 487. 
Dutroulau, Traite des malad. des Europeens dans les pays chauds. Par. 
1867, 87. 

Ehrenberg in Heckers' Annal, der wissensch. Heilk., 1827, vii, 16. 

Fenner, South. Med. Eeports, ii, 83. Fletcher, Madras Month. Journ. 
of Med. Sc , 1872, V, 197. Furlonge, Edinb. Med. and Surg. Journ , 
1830, Jan., 50. 

Galloway in Brit. Navy Eeport for 1872, 242. Goodeve (I), Calcutta Med. 
Transact., is. Goodeve (II), in Indian Annals of Med. Sc, 1854, Jan., Nr. i. 

Hamilton, Dublin Quart. Journ. of Med. Sc, 1836, Aug. Hester, 
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Jackson, Brit. Navy Eeport for 1S72, 206. Jarvis, Statist. Eep. on the 
Sickness and Mortality iu the Army of the U.S. from 1839 to 1855. 
Washingt., 1856, 365. 

Kennedy, Calcutta ; Med. Transact., i, 371. Ketchum, Transact, of the 
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Lafond, Madras Mouthl. Journ. of Med. Sc, 1873, vii, 418. Lallemant 
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1829, April, 33. 

Mackinnon in Indian Annals of Med. Sc, 185,^, Jan., Nr. iii. Marsh, 
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Wragg, Charleston Med. Journ., 1851, Jan, 


A. The English Siveatioig SicJcness} 

§ 19. Historical Outbreaks: the Symptoms. 

In August, i486, shortly before the battle of Bosworth 
Field, won by tbe army of Henry VII, a destructive disease 
broke out among the troops, to whicli the name of sweating 
sickness was given, from its most important symptom. It 
spread rapidly over the whole country, carrying off many 
victims wherever it appeared, and it died out towards the 
end of the year, probably in November. The same pesti- 
lence broke out anew in London in the summer of 1507, but 
this time its diffusion was less extensive, and it had dis- 
appeared before the end of autumn. A third outbreak of the 
sweating sickness took place in July, 15 18. On that occasion 
also the epidemic began in London, and it spread over a great 
part of England Avithin the next six months ; it is reported, 
but on somewhat unreliable evidence, to have been even 
prevalent at Calais among the English living there. In 
all the epidemics up to this time, not counting the occur- 
rence at Calais just mentioned, the disease had been 
confined exclusively to England (Scotland and Ireland being 
completely exempt), but on its fourth outbreak, in May, 
1529, it spread over a large part of the Continent of Eui'ope. 
This time also the sickness began in London, and having 

' A full list of all the accounts of the English sweating sickness given by 
contemporary physicians or chroniclers will be found in the ' Scriptores de 
Sudore Anglico superstites, &c.,' Jena, 1847, drawn up by Gruuer, and completed 
and published by Haser. There is a detailed history of the sicknes?, also with a 
complete list of authorities, among the historical and pathological writings of 
Heckcr, edited by me, under the title " Die grossen Yolkskrankheiten des Mit- 
telalters," Berlin, 1865. 


spread with great rapidity over the whole of England to the 
Scottish border, which it did not cross, it appeared in July in. 
the Baltic and North Sea ports of Germany, and withia 
the next five months it had extended from them over the 
whole of Germany, as well as through the Netherlands, 
Denmark, Sweden, Livonia, Lithuania, Russia, and Poland. 
In Switzerland, where the sickness occurred first in Decem- 
ber, it was limited to the northern part (Basel, Solothuru, 
and Bern), while France and the countries of southern 
Europe escaped it altogether. Another tAventy-five years 
passed by without a single trace of this malady showing 
itself anywhere, when in April, 155 1, it broke out anew in 
England, this tim^ at Shrewsbury, and overran the whole 
country with great virulence as far as the Scottish border, 
dying out in September. The Continent of Europe, as 
well as Scotland and Ireland, into which the pestilence had 
never penetrated, remained quite unaffected by this epidemic, 
although, according to a very doubtful rumour, cases of 
sweating sickness occurred at the same time among the 
English living in foreign countries such as France, the 
Netherlands, and Spain. 

The descriptions which contemporary writers have left 
of this disease, afterwards known by the name of " the 
English sweat,^^ have in general a stamp of uniformity, 
although it is plain that the type must have been modified 
by local influences, particularly the kind of treatment fol- 
lowed, which was sometimes rational and to the purpose, 
at other times injurious. 

There were rarely any prodromal symptoms to an outbreak of the 
disease; it mostly set in abruptly, and usually in the night time, with 
chills followed by heats ; the patients complained at the same time of 
oppressive palpitations, headache, want of breath, a sense of pressure 
or tightness in the region of the stomach, and sickness. As these 
symptoms rose in intensity, along with general tm*gescence of the skin, 
a profuse sweat broke out over the whole body, accompanied, as some 
observers mention, by a spotted, papular or vesicular exanthem.' In 

^ Castricus, one of tlie most reliable authorities, who made his observations at 
Antwerp, compares the exanthem to the maculae of measles ; Tyengius, another: 
Dutch physician, speaks of " pustulje parvaa exasperantes ; " and an Eno-Tish 
observer, Stapleton, alludes to them as " macule quas rhonhcas [probably measles] 


cases running a favorable course, the morbid phenomena declined after 
twenty-four or forty-eiglit hours, the sweats became gradually less, an 
abundant flow of urine took place, the skin desquamated, and after a week 
or two the recoveiy was complete. A grave type of the malady was indi- 
cated at the outset by severe cerebral symptoms, intense headache, deli- 
rium, convulsions, and a quickly developed comatose condition {somno- 
lentia et inevitahilis sojior), in which it is said the patients invariably 
died unless they were aroused out of it. Among other serious sym- 
ptoms mentioned, were colliquative sweating and extreme scantiness of 
breath ; death would then occur with symptoms of dyspnoea or 
general paralysis, sometimes only a few hours from the beginning of 
the illness. One or more relapses were common, especially if the 
patient had sweated little in the first attack. 

The duration of the epidemic was at some places only a few days 
(three to seven), it was mostly limited to one or two weeks, and it was 
the exception for it to last several weeks. Despite this relatively 
short continuance of the sickness, the number of cases was enormous ; 
the mortality also was at many places very great, while at other places 
only a few died out of all the thousands that fell ill.' It is difficult at 
the present day to decide how far local circumstances, particularly the 
mode of treatment, may have influenced the deathrate; at all events, 
the diaphoretic method, which was part of the therapeutic notions of 
the time, contributed materially to the high mortality. It was not 
until the later epidemics that the English physicians became con- 
vinced of the injuriousness of that procedure ; they confined themselves 
to a more expectant treatment, so that both in England and in Germany 
(where the rational practice did not become current until near the end of 
the epidemic) the sickness began to lose much of its terrible character, 
and the mortality to fall to a minimum. 

' Without venturing to trust implicitly to the data as to the number of deaths 
from sweating sickness at many of the localities, we should be justified, from a 
certain agreement among them, in concluding that the type of the disease had 
been disastrous in some places and very mild in others. Thus, more than looo 
persons are said to have died of it at Hamburg; at Freiberg (Saxony), 300, 
some say 600 ; at Copenhagen the mortality on some days appears to have 
reached the enormous figure of 400 ; at Augsburg there were 18,000 cases, with 
1400 deaths; in Antwerp the dead were counted to the number of 300 or 400 
witliin a few days. On the other hand, out of 4000 cases at Stuttgart only 6 
died, of 50 patients at Marburg only i died, while at Strasburg and other places 
in Alsace the deathrate was at a minimum, notwithstanding the enormous 
difEusion of the malady. 


§ 20. Associated Circumstances. 

As regards etiology, those who observed the pestilence in 
England brought forward the fact that its appearance on 
every occasion was preceded by heavy rains, and in some 
places by inundations ; on the Continent of Europe also, the 
epidemic in the summer of 1529 was ushered in by the same 
kind of weather and by widespread inundations. It was 
always in spring or summer that the disease appeared, and 
on no occasion did it remain longer than the beginning of 
winter. Communication of the disease through contagion is 
decidedly negatived by most of the observers, and these the 
most trustworthy, and we may therefore set aside the 
assertion of a few chroniclers that the sickness was carried 
in 1529 by ships from England to Hamburg. 

Finally, it should be mentioned that those in the prime of 
life and of the male sex suffered most ; children and the aged, 
if attacked at all, suffered less severely, and at some places 
the indigent part of the population enjoyed a striking immu- 
nity from the disease.^ 

Thus the '' English sweat,'' with its five outbreaks within 
the period from i486 to 155 1, forms a completed episode in 
the history of pestilence. Just as it appeared suddenly in 
i486 as a malady quite unknown to the doctors or to the 
public, a hitherto unheard of phenomenon, so in 1551 it went 
clean away from the earth and from men's memories, leaving 
no trace. Not until two hundred years after do we again 
meet with epidemic outbreaks of a kind of sweating sick- 
ness, which, if not identical with the English sweat, is still 
nearly related to it in every respect, whether superficial or 
essential. The history of it is sketched in its main outlines 
in the section that follows. 

1 Thus Kock and others report from Lubeck : " The poor people and those living 
in cellars or sleeping on the ground were free from the sickness," and Kenner, 
for Bremen, says : " The sweating sickness went most among the rich people." 


B. MiUary Fever. {Suette des Picards. Suette viiliaire.) 
§ 21, Confused Identity in Old Writings. 

In tlie middle of the seventeentli century attention was 
drawn in several parts of Germany, first at Leipzig and after- 
wards at Hamburg, Augsburg, and other places, to a severe 
disease of puerperal women, which had not been observed 
before, or not at least distinctively recognised ; from its 
predominant symptom, an exanthem, observers gave it the 
name of FrieseV- (the purples), fehris 'niiliaris, or imrpura. 
The exanthem was a lighter or darker shade of red, more or 
less uniformly spread over the whole skin, upon which millet- 
seed nodules (papules) or small blebs filled Avath serum 
(miliaria), often formed. The exanthem caused much 
itching, remained for a few days at its height, then faded, 
and was followed by desquamation of the skin. In the larger 
number of cases, the disease ran a fatal course, with sym- 
ptoms of great disturbance, such as high fever, quick pulse, 
want of breath, extreme restlessness, delirium, bleeding from 
the nose, and convulsions ; and not unfrequently death 
occurred even before the rash came out. 

It must remain an unsettled question which of the diseases 
now known to us this " childbed purples " corresponded to. 
Probably it was scarlet fever, which is well known to occur 
often in puerperal women, and to run usually a very un- 
favorable course. Moreover, at the period from which these 
reports come down to us, scarlet fever was not much known 
as a special form of disease, being hardly distinguished from 
other exanthematous diseases, especially from measles. There 
is the less likelihood of coming to a certain decision, for 
the reason that shortly after the publication of the first 
observations by Hoppe" and Gottfried Welsch,^ numerous 
eri'ors crept into the doctrine of "■ the purples ;" the exan- 
them, of all the morbid phenomena, was selected for notice 

^ The name is derived from the rough and reddened surface of the skiu, sug- 
gesting frieze. 

- 'De purpura dissertatio,' Lips., 1652. 

•* ' Historia medica novi istius puerperarum morbi, qui ipsis der Friesel dicitur,' 
Lips., 1655. (Resume in Haller, 'Disput. med. pract.,' v, p. 449.) 


among tlie group o£ symptoms ; the most various forms of 
disease, in which papular or vesicular exanthemata occurred, 
came to be called " purples/^ until at last simple sudamina, 
which were often produced abundantly by the then fashion- 
able diaphoretic practice, were brought within the compass 
of the term ; and in the end there was such a confusion of 
ideas as to render all attempts at an understanding futile. 
This obscurity in the meaning of " Friesel " continued in 
Germany into the nineteenth century ; and thus it happened 
that, when a disease that had been for the most part known 
only in France and Italy, under the name of " suette miliaire," 
came to be recognised about the beginning of the century 
in Germany, there was an opportunity for a further confusion 
of ideas, and the new disease was also received within the 
wide designation of " Friesel.^' Prolonged inquiries on the 
part of French and German physicians have cleared up this 
question to the extent, at least, that the vague term of Friesel 
has been quite given up. The conviction has gained ground 
that the " Suette miliaire '^ of the French, for which I have 
proposed " Schweissfriesel " as a German equivalent, has 
nothing in common with all those forms of disease in the 
seventeenth and eighteenth centuries that were included under 
the designation of Friesel, and that in the Suette miliaire we 
have to deal with an infective disease, an acute fever mostly 
epidemic, which is characterised by the sudden outbreak of 
very profuse perspiration with a penetrating odour, by a 
feeling of severe constriction at the pit of the stomach, by 
want of breath, palpitations, gastric symptoms, splenic enlarge- 
ments, sometimes even by cerebral symptoms, and by the 
breaking out, in the great majority of cases, if not in every 
case, of a rash, which is papular and vesicular, and occasionally 
bullous. This fever runs its course usually under eight days ; 
it has a very mild character in most epidemics, but in some 
the deathrate has been 20 per cent, and upwards of the sick.i 

^ A detailed account of the pathology and treatment of miliary fever, with a 
retrospect of the whole literature of the disease, is given in an article hy me in 
' Virchow's Archiv,' viii, p. 454, and in my edition of Hecker's epidemiological 
writings (' Die grossen Volkskrankheiten des Mittelalters,' Berlin, 1865, pp. 
363 — 392), to which I beg to refer the reader. 


§ 22. History and Chronology of the Epidemics in France. 

The history of miliary fever does not extend beyond the 
beginning of the eighteenth century.^ The first unambiguous 
information about the disease dates from 1718^ in which 
year^ according to the statements of chrouiclerSj it was 
observed for the first time in various parts of Picardy, 
whence the name " Suette ties Picards." The malady soon 
showed itself in Normandy, and next it spread over certain 
districts of Poitou, Ile-de-France, Burgundy, and Flanders. 
As usually happens on the sudden outbreak of diseases pre- 
viously unknown, the physicians of that period sought for 
the origin of the malady beyond the frontiers of their own 
country. Some laid the blame on pernicious winds blowing 
from the Netherlands coast over Northern France and carry- 
ing the pestilential poison with them (Bellot), while others 
explained the disease as having been introduced from abroad 
into the port of St. Valery (Ref. I). The repeated epi- 
demic outbreaks of the suette during the years following, 
within the limits of the localities mentioned, soon showed that 
these assumptions Avere untenable, and they proved that it was 
really some local origin of the malady that had to be sought 
for. Up to the end of the century it remained limited to the 
North and East of France ; at all events, according to the 
experience of Lorry, the South of France had escaped it 
altogether up to 1770. Miliary fever showed itself there 
first in 1772 and 1773, in Provence; it was still more widely 
spread in Languedoc in 1781 and 1782, and in the same 
years it was prevalent in the North-East of France to a 
greater extent than ever. Its area has gone on increasing 
in the course of the present century, so that the disease 
may now be looked upon as one of the most widely difi^used 
of the endemic or epidemic diseases that France suffers from. 

' The evidence adduced by Seitz and others {see the ' Bibliography ') from the 
writings of the physicians of antiquity, as well as of those of the middle ages and 
the earlier centuries of the modern period, in order to prove that these writers w ere 
acquainted with miliary fever, is based, in my opinion, upon an erroneous con- 
ception of the morbid process, which is essentially characterised, not, as that 
author assumes, by the exanthem, the least constant of the phenomena, but by 
the profuse sweat and by the nervous symptoms before mentioned. 



Chronological Table of the Epidemics of Miliary Fever in 
France from 1718 to 1879.^ 

Year Department. 



i7i8Somme Yiemeu, Abbeville, 

{ Amiens, &c., in Pi- 

I cavdy Summer^ 

Aisne St. Qnentin 

Orne At various places in 

j Normandy 

Nord 'in several communes 

j of Flanders 

1 723'Pas-de-Calais . .'Arras, &c., in Artois. . . 

,, Nord jCambray and neigh- 

1 bourhood 

1 726 Aisne 'Melun 

., ISeine-et-Marne Guise 


Ref. ii. 
r Ref. iii. 

Ref. iv. 
Ref. v. 

> Vandermonde. 

1732'Seine-et-MarneMeanx Spring Ref. vi. 

i733Somme Abbeville and other 

j I places in Picardy ... Summer Bellot. 
i734Bas-Rhin Strasburg lAut. & Win. Salzmann,Lindern 

1 735 Seine |Near Paris ,Sp. & Sum, 

Seine-et-Oise. . . Freneuse, Yexin fran^. 

Eure iVexin normand 


i738Seine-Oise Luzarche and Royau- 


'^ f Argentan, Yire. 

1739 Aisne 


Chateau-Thierry .... 

1 740 Seine-Marne . . . Provins [ Spring 

„ Eure Berthonville ' — 

1741 Seine infer iRouen ! Spring 

1742 „ Caudebec ! „ 

1747 Seine Near Paris Summer 

,, Seine-Oise Chambly & Beaumontj „ 

i748Mai-ne Chalons s. M ' — 

1750 Aisne | Guise and Gran villiers Summer 

,, Oise Beauvais — 

1752 Seine-Oise lEtampes -, Summer 

„ Mai'ne Sermaise ' ,, 

i755Allier Cussett Spring 

1756 Pas-de-Calais.. 'Boulogne s. M \ Summer 

1757 Puy-de-D6me.. In the years 1757-62 in 
j Low. Auvergue morei 

or less extensively...! „ 

i758Nord Lille „ 

Calvados Falaise Spring 

Allier Yichy Winter 

1 759 Seine infer Caudebec | Summer 

' The references in the column "Authorities" are to writings quoted in alpha- 
betical order in the list of authors at the end of the chapter. 


Lepecq, p. 256, 
323, 368, 419. 

Ref. viii. 

Foucart, p. 305. 


Rayer, p. 446. 


Lepecq, p. 156. 






Ref. ix. 

Meyserey, p. 5. 

Debrest (Ij. 


de Pleigne,Brieude 
Boucher (I). 
Lepecq, p. 156. 
iLepecq, p. 156. 



Year' Department. 


„ Allier 

„ Oise 

1760 Orne 

1 763 Calvados 

„ |Seine-Oise , 


1 765 Calvados 

1 766 Manclie . 
„ jOrne .... 

1767^,, .... 

„ Calvados. 

1 768 Manclie . 

1769 Allier .... 





Calvados .... 




Basses Alpes. 

Seine infer. 






Manche ... 


Tarn , 

Haute- j 



Saine-Oise ... 





Bas-Rhin ... 

Guise and vicinity ... 
Gannot, &c., in Cusset 



In many localities . . . 



Angerville, near 

Caen (especially Yorst. 
S. Sauveur) 


Laigle I 

Tinchebray ' 

Caen and vicinity 


Chambon de Comb- 
railles and vicinity 

On the Coast 





Ornison, &c., in Pro- 

At various places 


IBeauvais and vicinity 


Ghambon de Com- 

'Avranches, &c 


Castelnaudary, Cas- 
tres, St.Papoul.Car- 
cassone, Toulouse, 
Laveur, Perpignan, 
&c., in Languedoc... 

St. Reinan (Beauvais) 

Falaiso, Beaumont,&c. 

In many villages 

St. Foix, near Lyons. . . 

Meru, Corbeil, &c 


Beauvais and vicinity 

Rosheim and vicinity 










Autumn J 
Spring 7 
Winter ) 


Autumn J 






Debrest (II j. 



Lepecq, p. 347, 

I Ref. X. 


Boucher (II). 




[►Sp.^Su. }■ 




18 10 


181 7 

i82oBas-Rhin IDorlisheim Sum 





Sum. & Aut. 


Seine infer ' Arrond. of Yvetot. 


Somme jNear St. Yalery 1 Summer 

1821 Oise 7 'At many places over 

„ Seine-Oise ... j | a wide area 







JLepecq, p. 109, 135. 
Boucher (IIlj. 
Lepecq, 139. 

Rayer, p. 435. 

Pujol, Duplessis, 
Ref. xi. 

Rayer, p. 435. 






Rayer, p. 437. 

Schahl ct Hessert, 

Fodere, p. 78. 
Rayer, Moreau, 

Francois, Dubun 





Year Department, 


1 830 Seine infer Arrond. of Yvetot 

I S3 1 1 Vosges Plombieres 

1832 Oise General diffusion 

i Haute- Mar ne. 


Auxi-le- Cbaumont 

Seine-Oise 'Several villages 






Dordoffne A few communes 

Haute-Saone . . . ! Vesoul 

Bas-Rhin Rosbeim 

Dordogne Canton Mareuil 

Haute-Saone . . .; Vesoul 

Vosges Plombieres 

Aisne A few communes of 

j the AiTOud. Laon... 

,, iBellicovtr 

Seine-Marne ... General diffusion 

Dordogne [General diffusion , 








Tarn- Garonne 


Deux- Sevres ,. 
Haute-Saone . . 







Haute-Marne . 

General diffusion.... 



At very many places 

In a few villages 

In a few villages 

1846 Cantal. 



;; Var 

1847 Haute-Saone , 

1849 Somme 

Seine-Oise .... 

In a few villages .... 
In a few villages .... 


La Tere champenoise 




To a small extent 

Arrond. of Poitiers ... 

The village of Chau- 

Arrond. of Bezieres... 

To a small extent 

Arrond. of Brignoles 

Breurey (Arrond. Ve- 

In general diffusion... 

Noyon, Etampes, &c 




Sp. & Sum. 



Sp. & Sum. 


Summer ") 

„ ^ 

Su. & Aut. y 
Winter j 




Su. &'Aut. [ 
Winter J 

Wint. & Sp. 

Sp. & Sum. 



Meniere, Hour- 

Roljert (I). 
Bazin, Delisle, Du- 

bun (II). 
Parrot (I). 



Burthez, Bour- 
geois (I). 

Parrot, Borchard, 
Galy, Pindray, 
Pigne, Rayer 
(III), Martin 

Gigon, Genueil, 
Rayer, Martin- 
Solon, 11. cc. 

Mignot, Chabrely, 
Ref. xii. 

Burtez, Martin - 

Ref. xiii. 

Martin-Solon, I. c. 
Martin-Solon, 1. c 
Martin-Solon, I. c. 
Id., Arlin, Loreau, 

Gailiardj Mori- 


Martin-Solon, 1. c. 

Ref. xiv. 


Foucart, Bucquoy, 

Bourgeois (II), 



























Compiegne, Chambly, 

In general diffusion... 

Sezanne, Epernay, 
Fontenay, &c 

The vicinity of Verdxm 

A few communes of 
the Arrond. of Dole 

Several places in the 
Canton Niort 

A village in the Can- 
ton Bray 

1 '" \ 

) Sum. (. 

1 •■ { 









I Sp. C 

5 & Sum. I 


1 " { 

Sp. &. Sum. 





Foucart, Vernueil, 
Tourrette, Gaul- 


Reveille - Parise, 
Boinet, Guerin. 





Lachaise, Badin et 

Tauflieb, Ref. xv. 


A llaire. 

Nivet et Aguilhon. 

Gaultier (II), p. 

Id., p. clxxi. 
Id., p. clxxii, Buc- 


Id., p. clxv. 

Id., p. cLxxiv, Gryn- 


Gaultier (III). 



Stober et Tourdes, 

p. 414. 
Gaultier (IV). 
Stober et Tourdes. 


Stober et Tourdes. 

Barth (I), p. cxxvi. 

Desti'em, Jacquot. 
Barth (I), p. clxv, 







Deux-Sevi*es ... 



Arrond. of Condom ... 




Andlau, Nothalten,&c. 

Arrond. of Chateau- 




Several communes ... 

Cailleville (Arrond. of 


Seine infer 


Arrond. of Valognes, 



At several places in the 
Arrond Roisel 

Arrond. Florae at 
several places 

Arrond. of Pezenas . . . 

Arrond. of Beziers ... 
Two villages in the 

Arrond. Bernay ... 
One village in Cant. 







Arrond. of Mende 







Haute-Mame ") 
Seine-Marne ) 





Haute-Marne. . 


In many villages 


In considerable diffu- 


Arrond. Neufchateau 
At many places 

AiTond, of Pesmes ... 





1854 Jura 
„ Isere 



Haute- Garonne 



Cote-d'Or .... 

Arrond. of Dole . 
At a Monastery 


In general diffusion. 
Arrond. of Marvejols 
In general diffusion.. 
At many places 

'Loire . 



Herault .. 






Meurthe . 




AiTond. of Chalons 
and Epernay 





] - { 


Bass. -Pyrenees 

A village in Montbi-i- 


Arrond. of Chateau- 

Salins and Luneville 
Mutzig and Canton 


Longwy and Chaussin 
Arrond. of Beziers and 


Three villages in the 

Arrond. of Cognac! Autumn 

In many villages ! — 

AiTond. of Bagneres! Autumn 
At many points Sum. & Aut. 



Barth (I), p. clsii. 
Foucart (II). 
Barth (I), p. clxiv. 

Barth (II), p, clxiv. 

Id., p. clviii. 

Id., p. clxv. 
iStober et Tourdes, 

p. 414. 
Barth (II), p. cliv. 

Lozere . . 


Saone-Loire .. 






In a few villages of the 

Arrond. of Marvejols 

Arrond. of Tours 

Arrond. of Chateau 


Arrond. of Lonchans 
Arrond. of Perigneux 
Draguigan & vicinity 

Sum. & Aut.ild., p. cxlvii. 

Id., p. cxvi. 
Id., p. clvi. 
Id., p. cxcii. 
Id., p. cxciii, Ros 

Robert (II). 

Nontron , 

Arrond. of Castelnau^ 


St. Chinian 

St. Chinian 

Aisne "" 


Marne )■ 



Landes ^ 


Indre-et-Loire . 

Haute- Garonne 



1874 Puy-de-D6me 



In 34 villages 

In one village 

In one village 

In several villages 
Arrond. of Tours . . 

In one village 

AiTond. of CleiTuont 











Ref. xvi. 
Haime, Meusnier. 



Jolly (I)_. 

Ref. svii — Dumas, 

Jolly (II). 

Coural, Briquet. 










According to the above tabic, 194 epidemics of miliary fever 
have been recognised on French soil within the period from 
1 7 18 to 1874;^ of these the larger number have been limited 
to a single village or to a few localities, while others have 
been prevalent over wider areas, spreading even over whole 
districts or departments, and by their coincidence in time, 
particularly in the years 1832, 1842, 1849, 1853, 1854, and 
1855, they have imparted a pandemic character to the disease. 
The incidence of these 194 epidemics proves, however, that 
some parts of the country have been peculiarly subject to the 
malady, in contrast to others which have remained free. 
Thus we find that out of the eighty-nine departments (not 
counting Nice, Savoy, and Corsica), there have been fifty-five 
affected by the disease hitherto ; in twenty-one of these there 
has been only a single epidemic, in six there have been only 
two epidemics, in six others the disease has been a good 
deal more prevalent (Haute-Mame, Lozere, Pas-de-Calais, 
Puy de Dome, Indre et Loire, and Haute-Garonne), while it 
has broken out comparatively often in fifteen (Aisne, Seine 
infer., Calvados, Manche, Somme, Nord, Marne, Vosges, 
Jura, Haute-Saone, Allier, Seine-Marne, Eure, Orne, Dor- 
dogne, Herault), and in three it has been positively endemic 
(Seine-Oise, Bas-Rhin, and Oise). If now we place together 
those districts that have been attacked with especial fre- 
quency, we shall find that the disease has been very nearly 
confined to a strip of territory in the north-east of the country, 
extending from Franche-Comte through Alsace, Lorraine, 
the northern parts of Champagne, Flanders, Picardy, Ile-de- 
France, and Normandy, and including more particularly the 
departments of Jura, Haute-Saone, Bas-Rhin, Vosges, Haute- 
Marne, Marne, Nord, Pas-de- Calais, Somme, Aisne, Oise, 
Seine-Marne, Seine-Oise, Seine, Eure, Seine infer., Orne, Cal- 
vados, and Manche. One hundred and twenty-six out of the 
one hundred and ninety-four epidemics have occurred within 
the limits of that region, while the remaining sixty-eight have 
broken out (mostly at isolated spots, although sometimes 
they have become widely spread) in a few regions of middle 

• Tlic epidemics of miliary fever in Alsace and Lorraine having occurred at a 
time when these provinces were still French, I have counted them among the 
epidemics observed in France. 


and southern France^ particularly in Auvergne, in the adjoin- 
ing department of AUier, in the Dordogne, and in Poitou ; 
so that in the north-eastern group, including the three 
departments specially emphasised, the disease may be said 
to have had an endemic character. 

§ 23, Italian Epidemics. 

The first accounts of miliary fever in Italy, according to 
the writings of Fantoni and Allioni, date almost from the- 
same period when attention was first called to the disease in 
France. The earliest records, relating to the disease in 1 715- 
1753 in various parts of Piedmont, have not the trustworthi- 
ness that could be wished, as there has plainly been 
a confounding of exantheraatic typhus," scarlet fever, and 
other diseases with miliary fever. The accounts of an epi- 
demic in 1755 at Novara {AUioni, de Augustinis) may be 
taken as referring to miliary fever with more certainty, and 
still more so the statements of Damilano as to the wider 
extension of the disease in Piedmont in 1774. Among 
later accounts of the miliary fever in that part of Italy, there 
is one for the year 1 8 1 7, when it broke out in Novara at the 
end of summer after the extinction of an epidemic of typhus 
[Ramati], and for the years 1821-23, when it attacked several 
villages in the province of Alessandria, in the district situated 
between Sale and Camerane [Dalrnazzone). Wlien and to what 
extent miliary fever spread from the Sardinian territory over 
other parts of Upper Italy cannot be decided with certainty, 
from the scanty and in part hardly trustworthy records ; it 
would appear that the disease first became generally prevalent 
there towards the end of the second decade of the nineteenth 
century. Beyond the Sardinian Kingdom we meet with the 
malady first at Corregio (Modena), where it was epidemic in 
the summer of 1775 [Baraldi) ; next in Venetia, where it broke 
out first in 1790 at Verona, and is said to have spread thence 
westwards {PoUini, Arvedi) ; it was epidemic at Vicenza in 
18 1 7, somewhat later at Treviso, towards the end of the fourth 
decade at Padua,-^ still later at Venice [Taussig), while in 

^ Lippich ('Advers. Med.-Clin.,' Ser. ii, Fasc. i), sper^ks of miliary fever as 
disease unknown at Padua in 1835. 


several districts of Friaul it had been obsei'ved to be epidemic 
as eai'ly as the spring of 1835 {Podrecca). In the plain of 
Lombardy the disease appeared first at the beginning of the 
centur}'- on the banks of the Po {Jemina), especially in the 
district o£ Mantua, afterwards in the adjoining district of 
Brescia (Menis 1, p. 152), and not until the fifth decade did 
it penetrate to Milanese territory, to Pa via [Pignacca) , and 
Cremona {Tassani). Thus, a small epidemic of miliary fever 
■vvas observed by Storti in the summer of 1844 in the village 
of Pomponusio ; it was prevalent at Pavia in the hot summer 
of 1846, and in the district of Borgosatollo (Mantua) it was 
observed from the spring to the autumn of 1848 (Belpietro). 
In 1854 it bi'oke out as an epidemic at several places in the 
province of Brescia, and it reappeared there in the summer 
■of 1856, being especially malignant in Carpenedolo {Mara- 
cjlio). The most recent accounts of miliary fever come from 
Tuscany. In that province the disease showed itself first at 
Florence in the winter of 1836-37, according to Seitz, who 
follows Zink ; in 1843 ^^^ 1^44 i^ broke out there anew, and 
two years after it spread thence to Pisa, Leghorn, Poggibonzi, 
Fauglia, and other places {Taussig), since which time it has 
been repeatedly epidemic in those parts, particularly in 1853 
at Sangimignano {Cantieri), in 1854 at Ponte a Cappiano 
{Temjicsti) , in the winter of 1855-56 at Poggibonzi (Burresi) 
and Fauglia [Gattai), and in 1858 and 1859 again at Sangi- 
mignano [Cantieri). In the summer of 1861 it was prevalent 
-at Dovadola, imported, as Liverani explains, from Terra-del- 
Sole, after having been epidemic at Forli for a year pre- 
viously ; in the autumn of 1872 the sickness was observed, 
-according to the account of Borgi, in Galleno (circondario of 
SanMiniato), and in the summer of 1875 at Isernia. Fazio, 
to whom we owe the account of the last-mentioned epidemic, 
states that there could be no doubt of the epidemic preva- 
lence of the disease in the Aemilia, in some districts of Lom- 
bardy and Piedmont, and particularly in Tuscany. Whether 
■.Central and Lower Italy have hitherto escaped the miliary 
fever altogether, I have not been able to decide. The 
.account by Palmieri^ of a presumed epidemic of miliary fever 

1 ' Eclazioiie c semplicc cura della febre migliare, cbe La rcgnuta iu Bevagna, 
.&c.' Fuligno, 1805. 


iu 1S04 at Bevagua (delegation of Perugia) is not known to 
me; according to the summary of it by Corradi/ that epi- 
demic was in nowise concerned with the disease of which 
Ave are now speaking. 

§ 24. Other Epidemics, mostly German. 

Besides France and Italy, the only other country in which 
'miliaryfever has attained the importance of an epidemic disease 
is Germamj, and particularly its south-western divisions. Dis- 
regarding the altogether ambiguous accounts of " Friesel ^' 
•on German soil during the i8th century, — accounts from 
which, it is impossible, as we have seen, to obtain at the 
present day any definite notion of what disease they had 
'before them — we first meet with the disease in a few minor 
•epidemics, as at Wittenberg in the winter of 1801 {Gldser, 
Kreijssig), next in the spring of 1820 at a village in the 
neighbourhood of Bamberg {Speijer), and at the small 
town of Giegen in the Wiirtemberg district of Heidenheim 
{Steudel, p. 92), and in the summer of 1825 in a few parishes 
of the Bavarian justiciary district of Erdiug [Seitz, p. 334). 
The first accounts of a wider diffusion of miliary fever in 
'Germany date from the period between 1828 and 1836, or 
from the time of the more general prevalence of the 8uette 
.Tniliaire in France, and the first outbreak of cholera in 
Europe ; and during that period, as well as in previous years 
and subsequently, it was in the southern part of the country, 
more particularly in the south-west, that the disease was 
found to be especially common or to have the character of an 
endemic. In Wiirtemberg, miliary fever showed itself in the 
spring of 1829 at Oeffingen {Steudel, -p. 77), and at Ensingen 
'{Schnurrer), in the spring of 1830 in and around Mettingen 
■{Steudel, Manz), in the winter of that year and in the spring 
•of 1833 at several villages in the district of Gmiiud {Boden- 
miiller I), and in the winter of 1832-33 iu the district ol 
Yaihingen {Keyler). In Baden it broke out as an epidemic 
in 1828, 1833, 1835, and 1836 at several places in the circles 
of Main and Tauber (Eef. XIX), and in 1839 at Renchen 
' 'Anuall delle epidemie occorseiu Italia, &c.,' Parte iv. Bologna, 1877,51.568. 



(Schaihle). In Bavaria it was prevalent during tlie spring 
and summer of 1828 in the Roththal (on the western border 
of the circle of the Upper ]Janube, BecJi), in the winter of 
1833 in several villages of the justiciary district of Weilheim 
{Seitz, p. 358), and in May, 1834, at a village in the neigh- 
bourhood of Wiirzburg {Fuchs). In the years following, 
the disease was again not uncommon in the above localities, 
but it was mostly found in more isolated epidemics, often 
limited to quite small areas ; thus, in February, 1837, it 
occurred in two parishes of the Wiirtemberg district of 
Gmiiud {BodenmuUer II), in the spring of 1838 at Herlheim 
in Lower Franconia (Stahl), and in 1842 at Passau [Egr/er) ; 
but it was especially prevalent in the summer and autumn 
of 1844, when it spread from the justiciary province of 
Neumarkt, which had been often visited by it, to the districts 
of Milhldorf, Altotting, Vilsbiburg, Erding, Landshut, 
Dingolfing, and Landau, over a hilly tract of country sixteen 
leagues long and fourteen broad, situated partly in Lower 
and partly in Upper Bavaria {Seitz II, Ebersherger, Egger). 
Besides Wiirtemberg and Bavaria, it is chiefly in some of 
the mountainous parts of Austria that the disease has 
been found as an epidemic from time to time during the 
last thirty or forty years; thus, in Styria in the summer of 
1835 {Vest), and afterwards, in the sixties, in the Lasnizthal, 
where accounts make the disease to be quite endemic in 
several of the hilly parts {Macher) ; further, in Upper Austi-ia 
in the summer of 1836, in the spring of 1839 at Tarnow 
in Galizia {Kellermann) , and in a few of the mountain hamlets 
of the Saaz circle in Bohemia {Miiller), and more recently, in 
the autumn of 1859, in the small town of Ybbs in the circle 
of the Wiener Wald {Masarcl). In the epidemiological 
records of Central and Northern Germany, mention is indeed 
often made of '' Friesel " and epidemics of the same, but 
besides the small epidemic at Wittenberg in iSoi already 
referred to, only a few of them can, on tlie evidence, be 
assigned a place in the history of miliary fever. Such were 
the outbreaks in a village near the town of Meiuiugen in 
the summer of 1833 (Jahn), in the Kalau circle, province 
of Brandenburg, in the autumn of 1S38 {Tloedenhalc), in 
the small town of Frauenstein in the Saxon Erzgebirge in 


the winter of 1839/ and finally, in the winter of 1849 in 
the village of Wegeleben, circle of Oschersleben {Andreae). 
To these few data may be reduced all that is known of the 
occurrence of the disease in Germany. 

The accounts of miliary fever in Sivitzerland which have 
come down from the middle of last century are highly uncer- 
tain/ and equally unauthentic are the statements of French 
newspapers as to the occurrence of the disease in 1849 in 
Biscaya, Spain. So that, in addition to France, Italy, and 
Southern Germany, we find on the soil of Europe, as well 
as on the globe generally in so far as its conditions of disease 
are known to us, only one point where miliary fever has 
attained a degree of importance, and that but a slight one, 
viz. Belgium. The disease appeared there first in 1838 in a 
few communes of the Hennegau,^ next in 1849, along with 
cholera, at Liege, Namur, and in the vicinity of Mons 
{Leynseele), the year after at Hotton in Luxembourg 
{V Hcrmitte) , and finally in 1866, again in conjunction with 
cholera, in epidemic diffusion throughout many parts of 
Luxembourg (Ref. XVIII). 

§ 25. Limited Area. 

Few of the acute infective diseases have been so narrowly 
circumscribed in their geographical distrihution as miliary 
fever. Even within those narrow limits the disease has been 
mostly epidemic at scattered points only, or confined to a 
single village or a group of villages, seldom spreading over 
wider circles or over large tracts of country. This behaviour 
of miliary fever comes out. most clearly in Germany and 
Belgium ; in Italy also, if one may judge from the very in- 
complete data at our service, the disease appears to have been 
commonly prevalent in isolated or somewhat restricted epi- 
demics. In France alone has it overrun wide districts in 
certain years; as in 1757-62 in Lower Auvergne, 1772-73 in 
Provence, 1821 in the departments of the Oise and Seine-et- 

1 ' Physikatsberlclit im Konigreicb Sachsen,' 1839, P- 69; 1840-41, p. 163. 

^ See especially Allioni (German traiisl.), p. 19. 

3 Meynne, ' Topogr. med. de la Belgique,' 1865, p. 234. 


Oise^ 1832 in the Pas-de-Calais, Seine-et-Oise, Oisc, Haute- 
Marne, Haute-Saone, and Doi-dogne ; 1841-42 iu the Dor- 
dogne, Charente, Gironde, Tarn-ct-Garonne, Jura, Deux- 
Sevres, and Haute- Saone ; but particularly in 1849, ^^553-55, 
and 1866, when the spread of miliary fever over a great part 
of France gave the disease almost a pandemic stamp. 

§ 26. A Disease of Short Dukation. 

This character of limited diffusion in most of the miliary 
fever epidemics, has its counterpart in their strikingly short 
duration, wherein they correspond exactly to the English 
sweating sickness, and strongly remind us of influenza and 
dengue. The mean duration of epidemics of miliary fever at a 
given place has amounted to three, or at the most four weeks, 
and not unfrequently it has not exceeded a space of seven or 
fourteen days.'^ Even in those cases where the sickness was 
protracted over two or even three months, it usually happened 
that, during the first weeks, only a case showed itself here 
and there, then all at once a large number of persons 
would sicken, the epidemic quickly reaching its height and as 
quickly subsiding ; so that the duration of the disease in its 
proper epidemic prevalence was in fact limited to some two, 
three, or four weeks, while there was a further considerable 
period in which single cases occurred here and there until the 
outbreak came to an end." 

' The epidemic of 1833 in tlie neighbourhood of ]\reiniupen lasted eisht 
days, that of 1843 at Geipolsheim ten daj's, and those of 1801 at Wittenberg and 
1851 at Busson (Herault) fourteen days. 

^ Thus, we read in the account by Pujol (1. c), p. 274: "There is another 
peculiarity presented by our epidemic, which does not appear to have been 
observed elsewhere in so marked a manner. In the towns to which the miliary 
epidemic travelled, one met at first with a few individuals here and there who 
had the disease sporadically. But the moment the sickness became truly epidemic, 
people began all at once to be laid np with it by the hundreds every day, tlie 
number attacked within the twenty-four hours being greater every day for the first 
few days. After six or seven days the daily number of subjects attacked began to 
diminish, and went on decreasing for six or seven days longer, so that at the end 
of fifteen or sixteen days the miliary fever ceased to be epidemic and resumed its 
sporadic course as at first." Precisely the same sequence of events marked the 
epidemic of 1832 in the department of the Seiue-ct-Oisc, and also that of 1859 


Among those epidemics wherein the disease had attained a 
somewhat wider diffusion over large areas, there have been 
many differences noticed in its manner of beginning and of 
spreading, as well as in the length of time that it has con- 
tinued to spread. It would not unfrequently happen that 
many villages within a certain radius would be attacked by 
the disease all at once ; another time the sickness would 
spread to various sides along the radii, and as if from a 
centre, but without attaining an equal speed in all these 
several directions, or travelling equally far ; in still other 
cases, the diffusion has taken place by leaps and bounds ; 
or finally, the epidemic has travelled quickly in a particular 
direction, then remained stationary for a time, and after a 
considerable interval again travelled forwards, or it might be 
backwards. Thus, to take the example of the epidemic of 
1 841 in the Dordogne, the disease appeared first in June in 
the arrondissement of Nontron, in the north-west of the 
department, and from there it spread in a south-easterly 
direction to Mareuil and as far as the Drone, appearing the 
same month in a few communes on the left bank of the 
stream, although in very mild form ; but in July the miliary 
fever broke out in somewhat malignant form in localities 
that had hitherto remained exempt, and it now travelled 
very slowly in a southerly direction, so that at Perigueux, 
the most southern of the places invaded by the epidemic, the 
first cases occurred at the beginning of September, the 
height of the epidemic fell in the middle of that month, and 
the end of it in the first days of October. 

A very striking contrast to this narrow limitation which 
miliary fever has usually been subject to in its epidemic 
prevalence in time and place, is presented to us in the 
remarJcable extent that the ejndemic frequently attains in the 
places which it visits, an extent in some cases so considerable 
that influenza alone of common epidemic disease affords an 
analogy. Thus Pujol states that in the epidemic of miliary 
fever in 1782 throughout part of Languedoc, the number of 
the sick amounted to 30,000 ; in the epidemic of 1772 at 

at Ybbs; the latter lasted from the 15th September to the 31st of December, 
but, as Masarei remarks, by far the larger number of cases occurred in the period 
from the ist to the 15th October. 


Forcalquier (Provence), witli a population of 2000, there 
were 1400 cases, or 75 per cent, ; and at Busson (Herault) 
in 1 85 1, almost the whole population (or 800 out of 1000) 
were attacked by the disease in a space of two weeks. A 
rate of sickness of 25 to 30 per cent, of the whole popula- 
tion has often been observed ; the average numbers attacked 
in miliary fever epidemics, so far as we can judge from the 
data before us, may be put at 10 to 20 per cent, of the 
population ; while at the same time there have been not 
unfrequently epidemics with a sick rate of not more than 2 
to 9 per cent. 

Not less great than these variations in the ratio of sick- 
ness in epidemics of miliary fever, have been the fluctuations 
in the mortality of the disease at various times and in 
various places. Miliary fever in general is to be accounted 
a disease seldom fatal, and not a few epidemics can be 
adduced in which the mortality was zero ; such were the 
outbreaks in 1821 in the Seine-et-Oise, 1849 in the Oise, 
1 85 1 at Busson (Herault), 1853 at Boulogne (Haute-Marne), 
1854 in the Vosges and Haute-Marne, and 1855 at Cognac 
(Charente). In others the mortality has amounted to not 
more than i to 5 per cent, of the sick; as in 1821 in the 
Oise, 1S42 in the Dordogne and most parts of the Lot-et- 
Garonne, 1851 in Carentan, and in 1855 in the arrondisse- 
ment of Bagneres. On the other hand, we know of not a 
few epidemics in which the mortality reached the figure of 6 
to 13 per cent., notably in 18 12 in the Bas-Rhin, 1832-33 
in the Seine-et-Oise, 1839 in the Seine-et-Marne, 1841 in 
the Dordogne, 1849 ^^ Niort, Dole, &c., 1851 at Florae, i860 
at Draguigan, 1854 at Ponte a Capiano, 1801 at Wittenberg, 
and 1844 in Bavaria. Finally, there are a number of 
statistical facts showing a mortality of 15 to 30 and even up 
to 50 per cent, of those attacked by epidemic miliary fever ; 
but that proportion is obviously exceptional, and it has been 
found most frequently where the epidemic has been very 
limited in extent. 


§ 27. Close Dependence on Season and Weather. 

Among the factors which exert an appreciable influence 
upon the production of miliary fever, the foremost place is 
unmistakeably taken by the season of the year and the 

Among the 184 epidemics in the synopsis given above, in 
which the time of appearance and prevalence of the disease 
is accurately stated, the seasons were as follows : 

46 in spring. 

16 in spring and summer. 
I in spring, summer, and 
77 in summer. 

6 in summer and autumn. 
8 in autumn. 

1 in autumn and winter. 
27 in wintei". 

2 in winter and spring. 

Of the 184 epidemics, there were accordingly 83 beginning 
in summer and 63 in spring, while only 29 began in winter 
and 9 in autumn, so that nearly seven-ninths of all the epi- 
demics ran their course during spring and summer. The 
reason for the prevalence of miliary fever in those seasons 
will have to be sought for in the conditions of weather proper 
to them, and in fact it appears that a high temperature 
liable to sudden changes and associated with a large amount 
of moisture in the air is especially favorable to the outbreak 
and prevalence of the disease. It is a noteworthy fact in 
this connexion that most of the winter epidemics of short 
duration (two to three weeks), such as those of Vichy in 
1758, Douay m 1791, Wittenberg in 1801, Esslingen in 1831, 
Eosheim in 1832, and Weilheim in 1833, broke out and ran 
their course at a time of very relaxing and damp weather. 

§ 28. Influence op Locality. 

The influence of locality, particularly of the soil, on the 
occurrence and diffusion of miliary fever is not so obvious. 
Many observers lay much stress upon the prevalence of the 
disease on damp or marshy ground. At the first outbreak 
of the disease in 17 18, in Picardy, it was pointed out that 
the epidemic spread along a damp valley on a peat soil, 
while the adjoining plain, with a dry chalk bottom was 


unaffected ; it was remarked, farther, that miliary fever often 
occurred at Cusset, situated in a damp valley ; and it was 
shown that the epidemic of 1782 in Languedoc travelled 
exclusively along the Canal du Midi, and that the sickness 
of 1772 and 1773 in Provence, as well as that of 1812 in 
Alsace, was confined to deep and damp valleys, in the one 
case of the Alps and in the other of the Vosges, the high 
and airy localities having been affected very little or not at 
all. When the disease was prevalent in the vicinity of 
Bamberg in 1820, attention was directed to the low and damp 
situation of the locality attacked ; in the Roththal in 1828 
the epidemic was restricted to the low-lying and marshy 
villages, while the high ground escaped. The outbreak of 
miliary fever in 1829 at Ensingen was preceded by an 
inundation of the marshy region. The situation of Herlheim, 
where the disease broke out in 1838, is a wet moor. Barthez 
found in the epidemic of 1839, in the canton of Rebais, that 
the villages situated in a close valley much subject to inunda- 
tions were principally affected. It was proved that the 
sickness of 1841 in the Charente was particularly prevalent 
on the marshy banks of the Lione, and that it decreased in the 
extent of its diffusion and in its severity the farther inland 
it travelled. Wlien it was prevalent in Bavaria in 1844, it 
spared the lofty and dry situations and confined itself princi- 
pally to the long valleys, damp, marshy, or boggy, and 
enclosed by a circle of hills. In like manner, in the epi- 
demics of 1844 and 1849 i^ ^^® department of the Oise, it 
was principally the damp and marshy places that were 
visited ; and the same etiological factor was conspicuous iu 
the 1849 epidemic at Thionville and around Vesoul, and 
again in 1851 at Carentan, in 1856 at Neuhof, in i860 in 
Belgium, where the places affected by the inundations of the 
Ourthe were attacked first, and in 1859 at Ybbs where it 
was again the lower parts of the town, damp and exposed 
to frequent inundations, that suffered, along Avitli some 
adjacent villages situated in Avet meadows. In the depart- 
ment of the Puy-de-D6me the villages to suffer most were 
those occupying the water-logged banks of the Limange, and 
in fact the outbreak of the disease was usually preceded,, 
especially in the epidemic of 1866 at Davayat and in that of 


1874 at Clermont, by considerable floods. However deserving 
of attention these facts must always be in estimating the 
pathogenesis, it should not be forgotten, on the other hand, 
that miliary fever has not rarely broken out under entirely 
opposite conditions of soil, — that it has avoided the low-lying, 
damp, or marshy localities to become prevalent on dry ground 
and on airy plateaus. Thus we find the disease dominant on 
the chalk soil of Northern France, dry on the whole and in 
part sterile ; and on the rocky precipitous coast of Normandy 
(particularly Calvados). In the department of the Oise it 
was principally the elevated and dry localities that suffered 
in the epidemics of 1810, 1821, and 1832, in contrast to those 
of 1 844 and 1 849 ; and we find the same to be true of the 
disease as it occurred in 1820 at Giengen, and in 1830 at 
Mittingen and Gmiind, in 1841 in the Dordogne, 1842 in 
the Lot-et-Garonne, 1844 in Poitiers, 1849 in the depart- 
ments of the Somme, Aisne, and elsewhere, 1 85 1 at Peronne, 
1853 at Menetaux, 1854 at Viriville, and in 1866 at Pernes- 
en-Artois in the Pas-de-Calais.^ Finally, it has to be 
mentioned that in Upper Italy the disease showed itself 
first in the mountainous parts of Piedmont, and remained 
there for some time before there was any general diffusion 
of it over the plain of the countiy, while even in the latter- 
situation it was by no means associated with a swampy 
condition of the ground. 

§ 29. A CouNTEY Disease, but not paeticdlarly op the 


The outbreak and diffusion of miliary fever may be shown 

to be entirely independent of the neglect of hygiene which goes 

alongwith the hardships of living. It is especially noteworthy in 

this connexion that the disease has appeared almost exclusively 

in small country communes, in market villages and such-like 

localities, while in larger towns it has been extremely rare 

and of brief duration, never attaining the importance of an 

' In the account by Plouviez, it is stated (p. 36) : " The epidemic broke out in 
a low and marshy locality overgrown with trees. Of the six communes attacked 
three had those conditions, while the other three, again, were much elevated above 
their neighbours, with little wood on them, dry and a iry. Apart from considerations 
other than those of locality, the gravity of the sickness was always the same." 


endemic disease, as it does in tlie former class of localities. 
The disease has been prevalent repeatedly in communes 
distinguished by their cleanliness, the adequate ventilation 
of their streets and houses, the well-being and sobriety of 
life of their inhabitants and by other favouring hygienic 
factors, whilst other communes near them, and far inferior 
to them in all hygienic matters, have escaped. Wherever it 
has appeared, it has attacked rich and poor in equal propor- 
tions ; it has indeed happened not rarely that the proprietary 
class has furnished a larger contingent of the sick than 
those suffering from scarcity and want, as, for example, 
in the first Italian epidemics, in those of Strasburg in 
1734, Novara in 181 7, the department of the Oise in 18 12, 
the Dordogne in 1842, Poitiers in 1844, the departments of 
the Somme, Seine-et-Oise, and others in^ 1849, ^^^ ^^ 
Peronne in 1851. Aggregation of large masses of people 
in narrow and ill-ventilated spaces, such as barracks, 
prisons, hospitals, schools, and the like, so far from proving 
favorable to the development and diffusion of miliary 
fever, would even appear to have exerted an antagonistic 
influence. Thus Parrot^ says of the epidemic of 1841 in the 
Dordogne : " Observation has shown in the clearest way that 
the more the individuals were crowded together, the smaller 
was the proportion of cases and the less serious their type. 

At Perigueux, all the establishments with a large 

number of inmates were spared : the barracks, in which two 
batallions were usually quartered, were Avithout a single 
patient ; the college, where the vacation did not begin until 
after the first eight days of the epidemic, had not a single 
pupil attacked ; and in the prisons, which usually contained 
100 to 120 persons, there were only three cases of the mildest 
kind." To the same effect Gaillard^ speaks of the epidemic 
of 1 844 in Poitiers : ^^ Neither the inmates of the hospitals, or 
of the garrison, nor the applicants for public charity, were 
affected by it ; well-to-do workmen, and persons belonging 
to the rich bourgeoisie, and to the tradesmen class, were the 
sole victims of the epidemic.^' In like manner, Bucquoy 
says of the epidemic of 1851 in the department of the 
Somme : '' The miliary fever had this peculiarity, that it 
1 L. c, p. 191. 2 L. c, p. 51. 


showed itself to be most severe wherever the hygienic con- 
ditions appeared to be the most favorable." 

§ 30. A Specific Infection : Relations to other Diseases. 

There is complete unanimity among observers as to the 
specific character of the process of miliary fever ; but the 
views begin to diverge upon the question whether it is a 
jjeculiar specific morbid poison that we have to deal with, or 
whether the poison is to be regarded merely as a modifica- 
tion of the marsh miasm, that is to say, malaria. The 
supporters of the latter opinion seek to establish it by means 
of evidence that miliary fever is especially common, as we 
have already seen, on marshy and malarious soil, that a 
remittent type has been often observed in the course of the 
■disease, and that the use of quinine in such cases has had a 
good effect. An impartial estimate of the facts already 
adduced in detail makes it at least highly probable that 
copious saturation of the ground brought about by heavy 
atmospheric precipitations or by inundations is an essential 
factor in the production of miliary fever, and that under these 
circumstances there may be processes set up within or upon 
the soil which stand in some relation to the development or 
cultivation of the morbid poison, the disease being in this 
respect allied to yellow fever, to cholera, to typhoid, and, 
indeed, to the malarial diseases themselves. But as we are 
in no wise justified in concluding that there is an identity of 
the morbid poison underlying all those diseases because they 
have one etiological factor in common, so there is just as 
little reason to conclude for the identity of malarial disease 
and miliary fever. With all the extensive diffusion which 
the latter has attained in France, it is precisely the 
great marshy and malarious regions of the country at the 
estuaries and in the lower basins of the Loire, Garonne, 
and Rhone, that have remained altogether exempt from 
or been rarely visited by it. In the epidemic of 1844 in 
Poitiers, the town itself situated on a dry limestone ridge, 
together with the dryest spots in its vicinity, suffered most, 
while the marshy districts in the neighbourhood were entirely 
exempt. The river valleys in the department of Herault, in 


which miliary fever has been often epidemic, are completely 
free from malaria, according to the testimony of Coural, Ber- 
nard, and others. In the epidemic of 1841 in the Dordogne, 
it was actually in the elevated regions with a chalk bottom that 
the disease was prevalent, while the adjoining swampy dis- 
tricts were unaffected ; and although several chroniclers of 
the epidemic of 1849 in the department of Gers would make 
out the malarious soil of that tract of country to be the 
cause of the disease, still we cannot, in justice to facts, over- 
look the question why the marshes of Gascony, abounding in 
malaria, were for more than a century free from miliary 
fever, and on the whole so little visited by it when the 
disease did at length break out. The distribution of the 
disease also in Italy and Germany tells against the view 
here referred to. In the former, it is precisely the most 
intense foci of malaria on the swampy banks of the Po, 
especially the notorious marsh districts of Ferrara and Co- 
macchio at the river mouth, that have been least visited by 
miliary fever. In Germany, again, the disease has been 
prevalent almost exclusively in those districts which must 
be counted among the least malarious in the whole country. 
The remittent type of the morbid process, which has been 
sometimes observed, will hardly justify the conclusion as to 
the malarious nature of the disease ; still less the good effect 
of treating with quinine, which has, besides, been questioned 
by many. 

Of the nature of the morbid poison itself, we are not able to 
form an opinion, and equally little are we able to determine the 
influences upon which depend modifications in the course of 
miliary fever epidemics, and above all, the amount of sickness 
and mortality in them. In many cases, the reason for the 
malignant character of the epidemic is to be looked for in an 
unsuitable therapeutic or dietetic practice, particularly in an 
irrational diaphoretic method ; but in many other cases, this 
reason, often dwelt upon in too one-sided a manner, does 
not suffice to explain why the epidemic grows apace and why 
the sickness becomes of a more severe type. We are brought 
to a standstill here at those same confines of knowledge which 
mark the limit of our progress in the study of many other 
infective diseases — I mention only scarlet fever — and in 


forming a conclusion on this matter wc shall have to accept for 
the present the position of Bucquoy : " In the case of this 
as of most other epidemic maladies^ everything is still mystery 
to us ; after so many ages spent in research of every kind, 
we are still no farther forward than the quid occultam, quid 
divinum, of the father of medicine/' 

§ 31. Question op its Communicability. 

The question of the contagiousness or communicahilitij of 
miliary fever has been the occasion of lively controversies 
among French and Italian physicians. The reasons that 
have led Schahl and Hessert, Hayer, Loreau, Bucquoy, 
Robert, and others to answer this question in the affirmative 
are based chiefly upon the observation often made, that 
after one person has sickened of miliary fever, it is usual for 
the other members of the family to take the disease very 
soon, that in many cases the friends who have hastened to 
take care of the sick have become victims of the malady, 
and that in such cases the progress of the sickness from 
house to house can be followed, foci of disease being not 
unfrequently established from which the epidemic spreads 
or radiates. Foucart, who has taken the side of the con- 
tagionists, though not altogether definitely, thinks that an 
additional argument may be found for this opinion in the 
analogy, as he supposes, between miliary fever and the triad of 
acute exanthemata — smallpox, scarlet fever, and measles. 
The auti-contagionists, on the other hand, have pointed to the 
uniformly negative result of the experiments instituted by 
several physicians (Parrot, J3orgi, and others), to inoculate 
with the contents of the miliary vesicles, which, however, 
proves nothing as to the non-contagious nature of the 
disease, inasmuch as the morbid poison may possibly reside 
in other secretions. They have further dwelt upon the com- 
paratively rare occurrence of the disease in large towns, upon 
the more or less complete exemption from it, within the 
affected localities, of masses of people crowded together, 
the protection being in no wise due to isolation, and finally, 
upon the circumstance adduced by many observers in favour of 


their view^ that the children have for the most part remained 
healthy notwithstanding their close intercourse ^Yiih. sick 
members of the family, and that in innumerable cases the 
malady has not extended beyond one place, although that 
had been in free communication with the whole neisrh- 


bourhood. If, then, we have regard to the mode of out- 
break and course of the epidemic at particular places, as it 
has been described above, and to the manner of its diffusion on 
a large scale, there would seem to be the best reason for 
doubting the contagiousness or communicability {" trans- 
mission infectieuse,'^ as Foucart cautiously expresses it) of 
miliary fever in general. 

§ 32. Identity of Miliary Fever with the English Sweating 


A retrospect of the history of the English sweat and of 
the miliary fever, as here traced, leaves no doubt in my mind, 
of the close relations between the two diseases. Common 
to both are the sudden occurrence and the short duration 
of the epidemic, its prevalence in summer and autumn, the 
dependence of its origin upon the above-mentioned states of 
weather and corresponding states of the soil, the often 
observed immunity from it which the proletariat enjoys, the 
explosive outbreak of the disease, particularly in the night- 
time, the pronounced nervous symptoms as seen in the 
phenomena of anxiety, palpitation, want of breath (even to 
the extent of asphyxia and the like) the profuse sweats — the 
true signum pathognomomcum — the exanthem, which is for 
the rest as little constant in miliary fever as in the 
sweating sickness,'^ the frequent occurrence of relapses, the 
fatal termination ushered in by almost identical phenomena,, 
and finally, the injurious effects of the diaphoretic treatment. 
If there is any doubt left of the close connexion between the 
two diseases, it may be dispelled by recounting the history of a 

1 I leave it undecided whether the occurrence of an exanthem in the sweating 
sickness was actually so rare as the scanty notices of it would lead one to suppose; 
whether, indeed, it had not rather escaped the attention of ohservers who had 
not looked for it, and escaped their notice all the more that an examination 
of the skin had heen for the most part omitted for fear the patient should take 


sliglit epidemic of miliary fever in the autumn of 1S02 at the 
small Bavarian to^vn of Eottingen ; not only the internal or 
pathological affinities of the two diseases, but also the exterior 
or epidemiological are brought out by it in so striking a way 
that we might reckon this Rottingen epidemic as belonging 
in an equal degree to the modern epidemics of miliary fever of 
a malignant type, and to the older form of the disease, the 
English sweating sickness. 

The sickness broke out, according to the account given 
of it by Sinner,^ in the end of November, after a long 
tract of rainy weather following upon a hot and dry 
summer ; it lasted not quite two whole weeks, and was 
strictly confined to the town, all the country round having 
been entirely exempt. In this outbreak, as in others, it was 
chiefly strong people in the flower of their age that were 
attacked and prostrated, while the aged and the poorer class 
of people enjoyed a high degree of immunity. 

The onset of the disease was sudden, with palpitation, pain in the 
back of the neck, and profuse sweats ; in cases that ran an unfavorable 
course, there occurred " convulsive trembling of the whole body, swoon- 
ing, and torpor," whereupon death followed, mostly within the first 
twenty-four hours. Besides the palpitation accompanied by a feeling 
of anxiety, want of breath was always observed. In the less severe 
cases, the nervous phenomena went off, and only the sweating con- 
tinued, sometimes with the addition of exanthemata of various kinds 
("blebs, spots, or miliary papules''), while the secretion of urine was 
mostly suppressed. Such cases would usually end fatally, if, as not 
unfrequently happened, there was a relapse of the severe symptoms 
already described. When the issue was towards recovery, the per- 
spirations diminished gradually up to the sixth day, after which the 
patient entered upon convalescence in a state of great weakness. 

The mortality at the beginning of the epidemic was 
appalling; and, as in other instances, it was materially 
assisted by the mistaken diaphoretic treatment : it is in fact 
an open question whether that was not the sole cause of the 
excessive death-rate. The observer to whom we owe the 

1 ' Darstellung eines rheumatischen Schweissfiebers, welches zu ende November, 
1802, in dem churfiirstlich-wurzburgischen Stadtchen Eottingen a. d. Tauber 
endemisch berrschte,' WurzbiTTg, 1803. An exact reprint of tbis short but 
interesting tract will be found in the collection of Hecker's epidemiological 
works edited by me (Berlin, 1865, pp. 338 — 348). 


•account of it^ arrived only a few days before tlie sick- 
ness came to an end ; but, along with a practitioner who 
had already hastened to give his help — in the town itself 
there had been no medical attendance procurable up to that 
time — he instituted a suitable treatment, more cooling but 
still within such limits as to obviate a chill, with a strengthen- 
ing diet, and medicines for the period of convalescence ; 
and from that time only one case of death was observed. 

§ 33. Coincidence with Cholera Epidemics — " Cholera 


The history of epidemic sweating diseases is of special 
interest from one other point of view : the coincidence in time 
and iilace of the epidemics of miliary fever and cholera. The 
interest attaching to this fact has been materially increased 
by some recent information about certain forms of disease 
described under the names of " sweating sickness " and 
" cholera sudoral," which point to a degree of connexion — 
extrinsic or intrinsic — between the two diseases. 

At the first outbreak of cholera in France in 1832, attention 
had been drawn to that coincidence, the more so that miliary 
fever then became generally diffused after a quiescent period 
of eleven years, and began to spread simultaneously with 
cholera in the departments of the Oise,^ Seine-et-Oise,^ and 
Pas-de-Calais. ^ The same fact was observed over a still 
larger area in the second epidemic of cholera in France in 
1849 '> miliary fever then became again widely prevalent in 
the most diverse parts of the country, and there are many 
records showing the coincidence of the two diseases in 
time and place in the departments of the Marne,'* Seine-et- 
Marne,^ Oise,^ Seine-et-Oise,^ Sommc,^ Yonnc,^ Puy-de- 

' Meniere, Hourmann. 

* Dublin. 

^ Defrance 

^ Boinet (for tlie arrondissement of Epcrnay), Reveille-Parise (for Fontenay). 

* Gaultier. 

^ Verueuil, Tourrctte. 

7 Bourgeois (for the arrondisscmeut of Etampe-). 

s Foucart, Bucquoy. 

5 Lachaise, Badin et Sagot.< 



Dome,' Gard/ and Herault.^ lu the year 1853 the two diseases 
again occuiTed epidemically side by side* in the departments 
of Haute-Marne and Seiue-et-Marne, and in like manner we 
find them closely associated in the widest diffusion in 1S54 
and 1855 in the departments of Haute-Saone/ Vosges,^ 
Haute-Marne/ Cote-d'Or/ Aube,^ Haute- Garonne,^^ Herault,^^ 
Jura/^ Meurthe/^ Charente,-^* Landes,-^^ Basses-Pyrenees/*' 
Hautes-Pyrenees,^^ and other departments.^^ Outside Prance, 
the same coincidence of cholera and miliary fever has not 
been observed, as far as I know, except in 1832, when, during 
the prevalence of cholera in Meiningen, miliary fever oc- 
curred in an adjoining village which was exempt from the 
cholera, and during the epidemics of 1849 ^^^ 1866 at many 
places in Belgium and Luxemburg. 

The relation to one another of those diseases, when 
they Avere associated, has been found to be different in 
different epidemics. Very often the epidemic of miliary fever 
has preceded the outbreak of cholera, and has disappeared as 
the latter epidemic developed ; this happened in the depart- 
ments of Cote-d'Or and Vosges,where, as Jacquot remarks, 
miliary fever was " an almost inseparable companion " of 

1 Nivet et Aguilhon. 
' Gaultier (for Beaucaire). 

3 Arnaud (in ' Revue therap. du Midi/ Oct., 1855, relating to Marseillan). 
■* Vergne. 
^ Bertrand. 

^ Destreui, Jacquot (especially for the arrondissements of Neufcliateau and 
Mirecourt, in the former of which 100 out of 132 communes were attacked by 
both diseases; in 94. communes about 19,000 persons suffered from miliary fever, 
at least 6000 from fully developed cholera, and 13,000 from cholerine). 
' Jacquot, Earth. 

^ Clausse (for La Manche), Dechambre. 
9 Hulliu. 

"^ Millou (in ' Journ. de Med. de Toulouse,' October, 1855, ^0^ Revel). 
11 Aruaud (1. c, for Marseillan), Saurel (in 'Kevue therap. du Midi,' Sept., 
1855, for Marviel), Earth (for the arrondissement of Bezleres). 
^^ Dechambre. 

1^ Earth (for Honssonville, arrondissement of Luneville). 
" Earth (for Cognac). 
15 Earth. 

^f* Mice ('Journ. de Med. de Bordeau.x,' Dec, 1855), and Rossoutrot (for the 
arrondissement of Bayonne). 
'7 Barth. 
'^ See also the account by Fievet (in the ' Gaz. des H6pit.,' 1854, No. 107;. 



cholera. At other times both diseases have broken out nearly 
simultaneously, have run the same course, and gone away 
together. Sometimes miliary fever, having been the fore- 
runner of cholera, has continued during the epidemic of the 
latter, and even survived it. More rarely miliary fever has 
come in the train of cholera epidemics. Lastly, both diseases 
have been prevalent at the same time in districts directly 
adjoining, in such a manner that the epidemic prevalence of 
the one disease has excluded the other ; thus, in the depart- 
ment of Cote-d'Or, at the village of La Marche with 2000 
inhabitants, there were 97 cases of miliary fever and only 
43 cases of cholera, while at Flammerans, adjoining, a con- 
siderable diffusion of cholera took place, with only scattered 
cases of miliary fever. 

Along with this coincidence in time of epidemics of miliary 
fever and cholera, a coincidence or combination of the two 
diseases has not unfrequently been observed in one and the 
same individual. Most usually this combination has found 
expression in a peculiar conformation of the miliary fever, cho- 
leraic diarrhoea and other symptoms of cholerine being added 
thereto ;^ or, miliary fever has developed itself in the course 
of cholerine, in such a way that the characteristic intestinal 
dejecta, the prsecordial anxiety, the muscular cramps, and the 
like, have given way before an outbreak of copious perspira- 
tion, and the miliary fever has thereafter pursued its regular 
course (Verneuil). These cases, in the unanimous opinion 
of observers, always ended favorably, only that convalescence 
was in most of them remarkably protracted and interrupted 
hj various obstacles, wherein they contrasted in a striking 
ananner with the relatively mild course of the simple disease. 
It happened much more rarely that cholera developed in an 
individual ill with miliary fever ; this has been either at the 
very commencement of the disease, in which case the 
sweating ceased, and there occurred cramps and collapse, 
and usually very soon death ; or, more commonly towards the 
end of the miliary fever or in the period of convalescence, 
when the incident has mostly led to a bad prognosis.^ 

1 Meniere, Foucart, Bucqnoy, Verneuil, Jacquot, Dechambre, Badiu et Sagot, 
Def ranee, Colson, Lacliaisc, Arnaut, Mice, Eossoutrot, and others. 

* Meniere, Ilourmann, Bartli (for Cognac), Boinet, Badin ct Sagot, Veigne, 


Lastly, it lias been very seldom.^ that miliary fever lias 
appeared during the course of cholera (Dechambre), or in the 
stage of reaction, or during the convalescence from it (Mice) , 
and the complication has, for the most part, brought no 
real danger to the patient (Dechambre). 

In view of the facts hero adduced, there appears to me 
to be no question at all that the coincidence of miliary fever 
and cholera, in the epidemic and in the individual, does not 
rest upon mere chance, but that there is a certain connexion 
iDetween the two diseases under the circumstances mentioned. 
We find still further support for this view in the latest 
records of pestilence, wherein we meet with peculiarly-con- 
stituted forms of sweating sickness observed at various parts 
•of the globe, always in the company of cholera and partly 
even sharing in the phenomena of that disease. These 
observations form an interesting complement to the history 
•of the sweating diseases. 

The first account of the form of disease in question occurs 
in Murray's" report on a malady described by him under the 
name of '' sweating sickness," which he had observed in 
June, July, September, and October, 1839, and in June and 
July, 1840, at Mhow (in Malwa), where he was stationed. 
Cholera was epidemic in the neighbourhood, but it occurred 
only in sporadic cases at Mhow itself, while malarial fever was 
prevalent there during the autumn at the same time as the 
sweating disease. 

The disease announced its attack witli a prodromal stage of several 
days, during which the patients, besides complaining of slight head- 
ache and pressure in the region of the stomach, suffered fi-om loss of 
appetite and sleeplessness, with watery stools several times a day, 
while the heart's action appeared to be notably weakened. Chills, with 
heats following, marked the onset of the developed disease, and at the 
same time there was an increase of the headache and of the associated 
symptoms before mentioned ; the patients complained of extreme ex- 
haustion, acute pain in the pra3Cordial region, and thirst, and they were 
very restless. Next there occurred watery discharges from the bowel, 
with little colour, sometimes also vomiting of similar matters, ci"amp 
in the extremities, want of breath, and a feeling of obstruction and 

' Boinet states that he has never seen this kind of combination, and many 
other observers consider it as rare (Dechambre). 

- ' Madras Quarterly Med. Jouni.,' 1840, ii, p. 77, and 1841, iii, p. 80. This 
periodical being rare in Europe, I consider a somewhat detailed account of this 
interesting observation to be called for here. 


anxiety in the prascordia; tlie pulse was small and quick, the heart's- 
impulse became imperceptible, and the skin was covered with running 
sweat. In the worst cases, all these troubles disappeared except the 
intense thirst, the oppression in the chest, and the profuse sweating ; 
but gradually the pulse became imperceptible, a comatose condition 
took the place of consciousness hitherto unimpaired, and death occurred 
often within ten hours of the onset. Yomiting and cramps were not 
specially prominent or constant phenomena during the course of the 
disease, while, on the other hand, complete retention of urine and 
absence of bile in the stools were always observed. When the course 
of the disease was favorable, the pulse became fuller and slower, the 
feeling of burning and oppression in the prsecordia went off, the dejecta 
became feculent and tinged with bile, the patient passed large quanti- 
ties of urine, and fell asleep to awake quite well ; or, in other cases 
less favorable and less prompt, the fever and running sweats persisted 
some time longer. The same series of phenomena often recurred after 
twelve to forty-eight hours ; not unfrequently there were even several 
onsets one after the other which, in the favorable cases, became more 
and more slight ; while in unfavorable cases the coma increased, lasted 
longer and longer, and the disease ended in death. But recovery might 
take place even in the most severe cases, and Murray saw one patient 
recover after lying comatose for three days. Convalescence was always 
marked by a great degree of weakness ; the patients, while getting 
well, often complained for a long time of an oppressive feeling 
about the heart, and not unfrequently there were relapses and 
recurrences. At the anatomical examination of two individuals who 
had died of this disease, Murray found a remarkably dark and watery 
state of the blood, serous effusion into the membranes of the brain, 
and much accumulation of blood in the thoracic and abdominal 
organs ; there were no important anatomical changes besides. He 
believed that death took place from urajmia, in consequence of the 
complete suppression of the urinary secretion which always occurred in 
the course of the disease. In the disease itself he discovers the type 
of miliary fever ; bvit there was at the same time one series of pheno- 
mena that proved unmistakeably, as he thinks, the near relations of the 
disease to cholera, while another showed its affinities to malarial fever.. 

Connecting naturally witli this narration, are certain ac- 
counts of a form of disease observed on European soil at a 
time when cholera was epidemically prevalent ; if it be not 
completely identical with the Indian sweating disease, it 
resembles it in a high degree, and shows, like it, a very 
close relation to miliary fever. Koux, a navy surgeon at 
Toulon, was the first to call attention to this peculiar sick- 
ness, and he gives a sketch of it ^ under the name of '' cholera 

' 'Union mod.,' 1855, Xo?. 27 — 32, 1857, Xos. 131, 139, 142, 143. 


•cutaue ou sudoral " based upon observations made by 
himself at that city in the cholera years, 1849, i^54j and 
1855; he touches also upon the accounts of other French 
naval surgeons^ who had observed the disease on board the 
French fleet in the Black Sea during the Crimean war at 
the time of the cholera epidemic of 1854. These accounts 
have been subsequently amplified; not to mention the less 
■complete data furnished by several other French physicians, 
there have been communications by Houles/ Bourgogno/ and 
Lespinois* on the occurrence of the same form of disease at 
the time of the cholera epidemic of 1854 in Languedoc (par- 
ticularly in Soreze, Eevel, and other places in the department 
■of Tarn) and in Conde (Nord). 

According to tlie description given by Roux, this disease, distin- 
guishable from the cholera then prevalent by the profuse sweats, the 
absence or scantiness of the discharges, whether vomit or stools, as 
well as by the frequent relapses and by its long duration, had usually 
a sudden onset, and that was especially often in the night; the 
patient was overcome by a feeling of extreme weakness resembling a 
swoon, and at the same time his face became pale, he felt cold, the voice 
changed, the pulse became slower, and sometimes also there was sick- 
ness and a desire to go to stool. When this painful condition had 
lasted a short time, or even several hours, a reaction set in ; the pulse 
rose, the body became warm, and there now broke out an inexhaustible 
(" intarissable ") sweat which ran like a stream day and night, so that 
the patient was obliged to have the bed linen continually changed. 
Gradually the perspiration and heat declined, and the patient now lay 
in a state of extreme exhaustion, the features sunken and of an earthy 
pallor, the extremities as if broken or seized with cramp, appetite and 
sleep destroyed, while there was a particularly troublesome sense of pres- 
sure and a feeling of obstruction at the epigastrium. After a few days, 
appetite, sleep, and strength returned, and the patient seemed to be in 
full convalescence, when suddenly a fresh onset occurred with the whole 
chain of symptoms as before, and fhese relapses would recur three, five, or 
six times, and even oftener, and at intervals either regular or irregular. 
The disease was observed only in adults, it ran an entirely favorable 
course, and even the manifold troubles that remained behind, such as 
the neuralgias, the feeling of oppression about the heart, the digestive 
disturbances, the capricious temper, and the like, went away com- 

• Ibid., 1855, No. 31. 

- 'Revue med.,' 1855, August, September. 

3 ' Lettre sur le traitement abortif du Cholera Asiatique,' Valenciennes, 1854, 
and in the ' Annal. de la Soc. Med. de Bruges,' i860, Nov., Dec. 

* ' Essai sur la Cholera cutane ou sudoral,' Montpellier, 1868. 


pletely in course of time.' The disease on board the French fleet in the- 
Black Sea, according to the descriptions of Beau, and that in Conde 
according to Bourgogne, and in the department of Gard according to 
Houles, assumed a similar form, but it wanted the peculiar intermis- 
sions, and was much more malignant ; it usually ran a fatal course with, 
pronounced symptoms of asphyxial cholera, excepting that profuse sweats 
took the place of the intestinal transudation. "In 361 patients," we 
read in Beau's account, " there were present all the most marked sym- 
ptoms of algid cholera : cyanosis, icy coldness of the extremities and of 
the tongue, cold sweats running over tbe whole cutaneous surface, in 
such quantity as to soak the linen of the patients in a few minutes and 
to macerate their epidermis ; absence of pulse at the wrist, extinction 
of the voice, rapid wasting, typical facies choleraica, very painful 
cramps, sometimes suppression of urine. The characteristic vomiting 
and diarrhoea were all that was wanting in many cases ; and therein lies 
one of the marked peculiarities of our epidemic. The copious diapho- 
resis which we have dwelt upon appears to take the place of the usual 
hypersecretion from the intestine." 

If we now put togetlier the facts stated in tlie preceding 
pages, with a view to forming an opinion on the nature 
of the disease-forms here described under the general desig- 
nation of " sweating diseases/' we shall find that one constant 
phenomenon, characteristic of and peculiar to all those 
diseases, is the morbidly increased activity of the skin, partly 
taking the form of an abnormal transudative process, partly 
breaking out in exanthems; we see also that these pathological 
processes are accompanied by decided indications of a pro- 
foundly disturbed circulation and nutrition, either caused by 
an affection of the nervous system, or at least accompanied 
by such an affection. So far from being able to assign a 
critical significance to the perspiration and exanthem which 
occur in the miliary febrile diseases in question, we must judge 
of the nature and character of these symptoms from the same 
point of view as we judge of other abnormal processes of 
transudation due to similar disturbances of a general kind. 
None of the processes of disease that are accurately known 
to us offers so striking an analogy in this respect, as the 
disease to which sweating sickness shows unmistakeable 
relations in another direction, viz. the cholera ; and this 
analogy is so strong that on the first appearance of cholera 

' It will be seen that this was not, as might he svu'raiscd, a form of pernicious 
malarial fever, partly from the fact that quinine was completely powerless in 
the disease, and also from the facts stated in the sequel. 


upon European soil, Hufeland drew attention to the resem- 
blance between it and the oklest form of sweating disease 
known to us, the sweating sickness of the English. The 
French observers, who have so often and so uniformly observed 
the epidemics of miliary fever to coincide in time with cholera, 
have identified the two diseases from the genetic point of 
view, cholera being taken to be a kind of internal miliary 
fever {" Comme une sorte de suette interne," as Dubun 
expresses it), and miliary fever a kind of '^ cholera of the 
skin " ; and they think that they have found material support 
for this idea in the hybrid form of cholera and miliary fever 
above described. 

Literature op Miliary Fever. 

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§ 34. Its Antiquity and Oeiginal Habitat. 

Few points in pathology have occupied tlie attention of 
students of the history of medicine more than the question 
of the origin and antiquity of the smallpox. In the sixteenth 
century a keen discussion had already begun as to whether 
that disease had been known to the physicians of antiquity ; in 
the two following centuries, and down even to the most recent 
times, the same question has been the subject of numerous 
learned controversies, without anything better than guess-work 
resulting from all these inquiries.-^ The first unambiguous 
statements about the disease from a medical source occur 
in the well-known treatise of the tenth century by Rhazes, 
' De Variolis et morbillis,'" in which it is taken as established 
that Galen was acquainted with the disease, and fragments 
given from the 'Pandects' of the Alexandrian physician 
Ahron, dating from the fifth or sixth century, from which 
it follows that he was well acquainted with the smallpox. 
Rhazes speaks of the smallpox as a disease generally known 
over the East, and the sanxe opinion is expressed by subse- 

' Among the writers on this subject most worthy of mention are: Hahn, 
'Variolarum antiquitates,' Briga;, 1833, and 'Carbo pestilens a carbunculis 
distinctus,' Vratislav, 1 736 ; Werholf, ' Disqu. de Variolis et anthracibus,' Hannov., 
1735, in ' Ejd. 0pp.,' Hannov., 1755, ii, 469; Moore, ' History of the Smallpox,' 
Lond., 1802; Willan, ' Miscellaneous Works,' Lond., 1821 ; Krause, 'Ueber das 
Alter der Menschenpocken,' &c., Haimov., 1825 ; Hitser, ' Lehrb. der Gescb. der 
Med.' (1876), iii, 18-59 (very thorough inquiry). 

^ In Arabic with Latin translation by Channing, Lond., 1776; another Latin 
version in Mead., '0pp.' Neapol, 1752, p. 51. [Eug. trausl.iby Greenhill, Syden- 
ham Soc, Lond., 1848.] 

^ In the treatise above mentioned; also in 'Continens Brix.,' i486. 


quent writers, by Ali Abbas/ Avicenna,^ and otlier Arabian 
physicians of the tenth and eleventh centuries, as well as by 
Constantinns/ who had been educated in Arabian schools ; so 
that the fact, otherwise well corroborated, of the general 
prevalence of smallpox during the splendour of the Arabian 
power, not only in eastern but in western lands as well, 
is placed beyond all doubt. It is more difficult to decide 
when and by what road the disease came to Arabia. Reiske* 
quotes the following passage from Massudi's '' Golden Mead :' 
" Hoc demum anno [i.e. in the second year of the siege of 
Mecca by the Abyssiniaus during the so-called Elephant 
War, or about the year 370 A.D.] comparuerunt primum in 
terris Arabum variolas et morbilli, quorum quidem aliqua 
fuerunt jam antea inter Israelitas, non tamen Arabum terras 
invaseruut, nisi tum demum ;" and a confirmation of this 
statement occurs in the writings of El-Hamisy,^ and in other 
Arabian chroniclers.^ 

Probably smallpox is the disease here referred to, and it 
is possible that the outbreak of it was connected with the 
invasion by the Abyssinians ; while the assertion that this 
was the first occurrence of the disease in Arabia can neither 
be made good nor set aside. But it would be more than seems 
warranted if we were to conclude from this that the original 
habitat of the disease has to be assigned to African soil ; for 
there are other and not less reliable sources of information 
which make out smallpox to have been prevalent much earlier 
in Asiatic countries, and to have been generally diffused in 
that continent at a time when it was hardly credible that the 
disease should have been imported from Africa. Holwell, 
who was for a long time resident in India, and whose tes- 

1 ' Regalis dispositionis Theorices,' lib. viii, cap. 14; 'Practices,' lib. iv, cap. 5, 
Lugd., 1523, fol, 97, 198. 

- ' Cauon,' lib. iv. Fen. i, tract, iv, cap. 6 fF., Venet., 1564, ii, 71. 

^ ' De morbor. cognitione,' lib. viii, cap. 8, 0pp. Basil. 1536, 152. 

* ' Opuscul. mod. ex monumentis Arabum,' Hal., 1776, 8. 

^ 'According to Bruce, 'Travels to the Sources of the Nile,' Loud., 1790, i, 
516. The clironicler narrates that flocks of strange birds (Ababil, the Persian 
term for smallpox) came over the sea to Mecca, each one carrying in its beak 
.and in its claws stones as large as a pea, which thuy let fall upon the Abyssinians, 
«o that their armour was pierced and the wliole army slain ; this w'as the time, 
the narrator adds, when smallpox and measles first broke out in Arabia. 

^ See also Haser, 1. c, p. 59. 


timony is deserving of all credit, states^ that iaiinemorial 
traditions have existed in the Brahmin caste concerning the 
prevalence of smallpox in India, that there has existed there 
since the earliest times the temple-worship of a deity whose 
protection and help was invoked on the epidemic outbreak of 
the disease/ and that there is contained in the Atharva Veda 
a description of this temple service together with the prayers 
used by the Brahmins at the inoculation with smallpox, which 
has been practiced there from time immemorial. Wise/ who 
gives a sketch from the oldest Sanscrit writings on medicine 
(the Charika and Susruta) of the spotted and pustular skin 
diseases, and among them of the smallpox, is convinced 
that this disease had been prevalent there at a very remote 
period ; and he makes the conjecture, which is, however, by 
no means well founded, that it came from India to the 
western parts of Asia, and thence to European and to African 
soil. An equally great antiquity has been claimed by 
Moore* for the diffusion of smallpox in China, on the 
authority of a treatise with the title, ' Heart Words on 
the Smallpox,' which had been edited by the Imperial Col- 
lege of Physicians ; this treatise is based upon the oldest 
writings of Chinese physicians, and in it the first appear- 
ance of the disease in Cliina is referred to the time of the 
Tsche-u dynasty^ or the period between 1122 and 249 B.C. 
According to Smith's researches,^ the disease appeared for 
the first time in that country during the dynasty of Han 
(206 B.C. to 220 A.D.) having been imported, as he adds, from 
Central Asia or from countries to the south-west, perhaps, 
therefore, from India. Both statements may be easily recon- 
ciled if we assume that the malady first appeared in the third 
century B.C., an assumption which agrees with the statement 

1 'Account of the Manner of Inoculating for the Smallpox in the East 
Indies,' Lend., 1767, p. 8. 

" This temple-worship is very widely spread in India; the goddess to whom it 
is offered, bears various names in various parts of the country, corresponding 
mostly, as it seems, to the character of the disease or to the mode of treatment. 
According to Moore (' Med. Times and Gazette,' 1S69, Nov., p. 634), numerous- 
temples of that kind are met with in Rajpootana. 

3 'Commentary on the Hindu System of Medicine,' Lond., i860, p. 233. 

* L. c, p. 21. 

5 'Medical Times and Gazette/ 1871, Sept., p. 277. 


of Lagarde/ -who puts tlie antiquity of smallpox in China at 
upwards of 2000 years. 

The question of the antiquity of smallpox in African 
counti'ies is entirely beyond our answering ; nor on European 
soil can the occurrence of the disease be traced back with 
certainty beyond the Christian era." The first references to 
smallpox for these countries, that are at all reliable, are met 
with in the fragments (preserved by Aetius)^ by the physician 
Herodotus, who lived at Eome in the time of Trajan; next come 
the accounts given by Galen* of the pestilences throughout the 
whole Eoman empire of the east and west, in the time of 
Antoninus (a.d. 160 — 168) ; then the description by Marius of 
Avenches^ of the epidemic that was Avidely prevalent in France 
and Italy in 570, wherein the name " variola " occurs for the 
first time as a designation of the disease ; and finally, there is 
the account by Gregory of Tours° of the sickness that over- 
ran a great part of Southern Europe in 580. Entirely un- 
ambiguous statements as to the prevalence of smallpox in 
Europe date from the eleventh and twelfth centuries ; and it 
is by no means improbable, as many chroniclers of that 
time agree in saying, that the tumultuous popular movements 
during the crusades contributed materially to the general 
diffusion of the disease. Almost all the medical writers of 
the middle ages mention the smallpox,'^ while sotue of them, 
such as Gordon,^ Varignana,^ John of Gaddesden,^^ Bertuc- 

* 'Arch, de mednavale/ 1864, March, p. 190. 

' There is little foundation for the opinion first expressed by Krause (op. cit., 
p. 50), and adopted by Daremberg (in Prus, ' Rapport sur la peste et les quaran- 
taiues,' Paris, 1846, p. 238), and by Littre (' Oeuvres completes d'Hippocrate,' v, 
p. 48), that the Plague of Athens daring the Peloponesian war, B.C. 428, as 
described by Thucydides, was an epidemic of smallpox. 

3 Lib. V, cap. 130, ed. lat., Basil, 1535, i, p. 226. 

* A complete collection of all the passages in the writings of Galen which bear on 
the question will be found in Hecker's ' De peste Antoniniana commentatio,' Berol, 
1835 J and in his ' "Wissenschaftliche Annalen des Ges. Heilkd.,' 1835, -^xxiij i- 

" ' Chronicou ' in Bouquet's ' Collection des historiens de France,' Paris, 1 738, ii, 
p. 18. 

" ' Historia Francorum,' vi, cap. 14, Parisiis, 1610, p. 263. 

^ Gruner ('De variolis et morbillis fragmenta medicorum Arahistarum,' Jen. 
179°) lifis published a toleralily complete collection of the more important 
accounts of smallpox in the writings of mediaeval physicians. A copy of this 
extremely rare work is in my possession. 

^ ' Lilium medicinse,' pars, i, cap. 12, Lugd., 1574, p. 51. 

9 'Secreta sublimia,' tract, ii, cap. i, Lugd., 1526, fol. 43. b. 

'" 'Eosa auglica,' Aug. Viudel, 1594, p. 1041. 


cio/ Geutilis de FuHgno/ Valcscus de Tliarauta/" Concorregio/ 
Antonio de Gradis,^ and Blasius Astainus/ treat the subject at 
greater lengthy but still in the spirit of their Arabian models, 
and entirely without regard to the epidemiological aspect of the 
disease. Consequently for the purpose of our epidemiological 
inquiry, we have to fall back upon the mediseval chroniclers ; 
but in them too there is very little to be found^ nothing, 
indeed, that justifies more than a conjecture that the small- 
pox played at any rate a prominent part among the pesti- 
lences of the middle ages. 

But, although the origin of smallpox still remains au 
unsolved problem, and its primseval history is still shrouded in 
complete obscurity, so much^ at least, appears to be made 
out for certain_, that this malady, like the plague, yellow 
fever, and other severe infective diseases, has its habitat at 
only one or two points on the globe, and that its diffusion 
over the earth's surface has been brought about by succes- 
sive importations of the morbid poison from those original 
seats. The native foci of smallpox may be looked for 
in India and in the countries of Central Africa. As we 
shall see in the sequel, it is not possible to make out 
clearly, except in a few instances, at what times the disease 
came from those centres to the several regions of the 
Eastern and Western Hemispheres. At the present time 
the dominion of smallpox extends over almost the whole 
inhabited globe, and there are only a few regions, as we 
shall see in the following account of its geographical distri- 
bution, that still enjoy a complete immunity from it. 

Although the introduction of vaccination into the more 
ci\"ilised states has greatly limited the amount of the disease, 
still the area of its distribution has undergone no real cur- 
tailment, and even at the present day smallpox remains one 
of the most widely spread of the acute infective diseases. 

1 ' Collectorium totius med.,' lib. ii, tract, i, cap. i6, Lugd., 1509, fol. 274. 
(This author has not found a place in Gruner's collection). 

^ ' De febribus,' tract, iv, cap. 4, Venet., 1503, p. 85. 

3 ' Philoniuui,' lib. vii, cap. 17, Lugd., 1490, fol. 326. 

■* ' Practica de curis febrium,' Venet., 1521, fol. 93, 6. 

5 ' De febribus/ cap. 26, in ' Clementii Clementini Lucubrationes,' Basil (1535), 
p. 279. 

^ ' De curis febrium,' in Gatinaria, * De curis segritudinum,' Lugd., 1525, 
fol. 75, b. 


§ 35. Geographical Distribution. 

One of the most intense foci of smallpox is met with on 
African soil, in the countries of the Nile basin, Er/ijjot, Nuhia, 
Kordofan, and the Ahyssmian Highlanc^s. "' It increases in 
frequency and severity/' says Pruner/ referring to these 
countries, "as we penetrate into the interior of this. part of 
the world, or, in other words, as we ascend the Nile ; it appears 
to be the one great sickness there." From the interior 
of Abyssinia it is often imported to the coast," so that, as 
Courbon states,^ one seldom finds an Abyssinian without the 
marks of smallpox. According to verbal statements made 
by Dr. Arnaud to Pruner, the Shillook country forms the 
southern boundary of this focus of smallpox, but there is 
reason to think that the endemic area of the disease reaches 
much farther, that it extends, in fact, to the interior parts of 
South Africa. One fact in support of this, given by Lostalot- 
Bachoue,^ is that smallpox is permanently active on the 
Zanzibar Coast and on the East Coast of Africa in general ; 
and another is that it never ceases its ravages in Madagascar,'* 
where an attempt has been made to introduce vaccination 
since the severe epidemics of 1866-67. Again, the fi^equent 
prevalence of smallpox among the natives of Cape Colony 
points to a central focus of disease in the interior of South 
Africa. Lichtenstein, who travelled through Kaffirland in 
1804, and found many of the natives pitted from the smallpox, 
became persuaded on penetrating farther into the interior, that 
the malady was widely diffused over the whole continent, while 

1 'Die Krankheiten des Orients,' Erlangen, 1847, p. 127. See also Hartmann, 
' Naturgeschicbtlicli-mecl. Skizzen der Xillaiuler,' Berl., 1865. Of its endemic 
occurrence in Kordofan there is an account by the physician Ebn-Omar-el-Jounsy, 
'Voyage au Darfur,' Paris, 1845; for Abjssinia (Shoa), by Rochet d'Hericourt, 
'Voyage dans le pays d'Adel,' Paris, 1841, p. 308. 

^ Martin, in the 'Lancet,' 1869, Jan., p. 140. 

3 'Observ. topogr, et nied. rec. dans un voyage h I'isthme de Suez,' Paris, 
1 861, p. 30. 

■* lEtude sur la constitution phys. et med. de I'ile de Zanzibar,' Paris, 1876, 
p. 47. 

^ Davidson, in the 'Med. Times and Gaz.,' 1868, Dec, p. 646; Borchgrevink, 
in 'Norsk Mag. for Laegevidensk,' 1872, iii. Raekke ii, p. 247. 


he did not find the remotest reason for believing that it had 
been imported from the coast. " All that I could learn on that 
subject/^ he says/ " served more and more to confirm the 
opinion of the Kaffirs that this disease is indigenous in Africa. 
The history of this people does not, indeed, go far back into 
antiquity ; but all the best informed persons among them 
were of one mind, that the malady had been prevalent in 
their midst as long as they had been a people at all. There 
could hardly be in their case any question of the disease having 
been communicated by Europeans ; for they dwell so far from 
the coast that even so recently as ten or twelve years ago 
the tales of a great water (the sea), and of white men, were 
counted among their fabulous legends, and did not find 
credence until the arrival of some Dutch travellers from 
Cape Colony. On the other hand, they told us of the 
Macquini (?), a great nation living far to the north, in the 
very heart of unexplored tropical Africa, from whom they 
had got their last epidemic of smallpox, transmitted through 
the tribes occupying the country between."" The disease 
was imported to Cape Colony, according to Murray,^ for the 
first time in 17 13 by a ship from India, next in 1755 from 
Ceylon, and afterwards in 18 12 by a slave ship from Mozam- 
bique, from which date down to 1840 the Colony remained 
free from the disease.^ [Cape Town and the country round 
about were visited by a very severe epidemic in 1882, with a 
high mortality.] 

In Reunion the smallpox became prevalent for the first 
time in 1729, having been introduced from Madagascar; the 
next outbreak took place in 1827, again in consequence of 
importation of the disease by a slave ship, to which source 
the later outbreaks in 1850 and 1858 are also traceable. In 
the intervals of these several epidemics, sporadic cases of 

' 'Hufeland's Journal der Heilkd.,' 1810, xxxi, pt. i, p. i. See also Fritscli, 
■'Arcliiv fiir Anatomie und Phys./ 1867, p. 738. 

■■^ Scherzer (' Zeitschr. der Wiener Aerzte,' 1858, No. 11, p. 166) calls attention 
to tlie fact that inoculation is generally practised among the Hottentots, the 
Dutch having introduced it, and that that race are much less apt to suffer from 
smallpox than the Kaffirs, who shun the practice, as they do also vaccination, and 
who often have the whole population of a village swept away by the smallpox. 

3 'Lond. Med. Gaz.,' Dec, 1833; Oct., 1834. 

-* ' Zeitschrlft der Wiener Aerzte,' 1858, No. 40, p. 630. 



smallpox Lave never becu observed.^ Mauritius, according' 
to Cbarpentior, has been often visited by epidemics of tlie 
disease under the same circumstances, without any sporadic 
cases occurring in the intervals. St. Helena had remained 
quite exempt down to 1 836 3" I have not ascertained whether 
this immunity has continued. There is no information 
forthcoming as to the occurrence of smallpox along the 
southern part of the West Coast of Africa. On the Guinea, 
Coast, according to the unanimous opinion of observers/ the 
disease is not indigenous ; it occurs from time to time as an 
epidemic, sometimes so disastrously that whole villages are 
ravaged by it. The same is true for the coast of Sene- 
gamhia,'^ where the endemic prevalence of the disease is 
absolutely denied by Gauthier/ and for the adjoining regions 
of Soudan,^ as well as the coast of the Barhary States, of 
Tunis^ and of Algiers^ The locality most affected in the 
last mentioned is Kabylia, where Claudot/ confirming Chal- 
lan,^° speaks of smallpox as the greatest scourge of the 
country. From the west coast, smallpox has been repeatedly 

' Azema, in the 'Arch. gen. de med.,' May, 1863. See also Toilet, in the 
' Revue med.,' Dec., 1834, p. 440. 

* McRitchie, in the 'Calcutta Med. Transact.,' 1836, viii, App. xxix. 

' Compare the accounts by Monnerot (' Consider, sur les maladies endemiques 
. . . . du Gaboun,' &c., Montpellier, 1868, p. 40) for the Gaboon country; 
for the Benin coast by Danlell (' Sketches of the med. topogr. ... of the 
Gulf of Guinea,' Lond., 1849, p. 48), and by Hewan (' Lancet,' 1877, Sept., p. 388), 
who states in an account of the severe smallpox epidemic of 1869 in Old Calabar, 
that the disease had not been seen in Benin for a space of eighteen years ; further, 
by Moriarty ('Med. Times and Gaz.,' 1866, Dec, p. 662) for the Gold Coast, and 
by Boyle ('Med.-Histor. Account of the Western Coast of Africa,' Lond., 1831, 
p. 400), Gordon ('Edin. Med. Journ.,' 1856, Dec), and Clarke ('Trans, of the 
Epidemical Soc,' i860, i, p. 102) for the coast of Sierra Leone. 

■^ Thevenot, 'Traite des malad. des Europeens dans les pays chauds,' Paris, 
1840, p. 249; Thaly, in 'Arch, de med. nav.,' 1867, Sept., p. 174; Berger^ 
' Consider, hyg. sur le bataillon de tirailleurs Senegalais,' Montp., 1868, p. 53. 

^ ' Des Endemies an Senegal,' Paris, 1865, p. 18. 

^ Quintin, who lived for two years in Segu, the capital of the kingdom of 
Bambarra, where no European had penetrated up to 1864, states that not a single 
case of smallpox occurred during that period. There, also, the disease breaks out 
now and then in disastrous epidemics (' Extrait d'un Voyage dans le Soudan^* 
Paris, 1869, p. 37). 

" Ferrini, ' Saggio sul clima e sulle malattie dell'regno di Tunisi,' Milano, 
i860, p. 151. 

s Bertherand, 'Medecine et hyg. des Arabes,' Paris, 1855. 

3 'Rec. de mem. de med. milit., 1877, p. 193. 

10 ' Gaz. med, de I'Algerie,' 1868, p. 115. 


introduced into the Cape Vcrd Islands^ and into the Canaries.^ 
In Asia Minor^ Sijria,^ and Mesopotamia^^ where they Lave 
not succeeded hitherto in introducing vaccination as a 
general practice in place of inoculation, smallpox still plays 
as prominent a part in the sickness and mortality as it 
used to do. This is true also of Persia^ and Arabia,'^ and in 
a still higher degree of India and Fiirther India, where the 
disease is thoroughly endemic over large tracts of country. 
Pringle, basing upon thirteen years' medical experiences in 
India, speaks of smallpox as the severest scourge of the 
country -^ if cholera, he says, carries off hundreds every 
3'ear, if the Anctims of famine are to be counted by thousands, 
these are but infinitesimal quantities beside the frightful 
amount of devastation caused in India by the smallpox. In 
the years from 1866 to i86g, in the Presidencies of Bombay 
and Bengal with a total population of forty millions in round 
numbers, 140,000 persons died of the disease / in the years 
1875 and 1876 the mortality from this disease in the whole 
of India amounted to 200,000, and in the two preceding years 
to 500,000.^° Among the regions of India most severely 
visited are many parts of the Presidency of Bengal,^ ^ 
particularly the Province of Orissa^^ and the southern 
slopes of the Himalaya -^^ in the Madras Presidency, the 
district of Madras,'* Pondicherry,'^ the Malabar coast,^*' par- 

' Hopffer, in 'Arch, de med. nav.,' 1877, March, p. 161. 

' Busto y Blanco, 'Topogr. med. de las islas Canarias,' Sevilla, 1864. 

3 West, in 'New York Med. Record,' 1869, March, iv, p. 27. 

* Robertson, ' Edin. Med. and Surg. Journ.,' 1843, July, p. 58; Guys, 'Statist. 
du Paschalik d'Alep.,' Marseille, 1853, p. 63. 

5 Ffloyd, in ' Lancet,' 1843, July; Evatt, 'Army Med. Rep.,' 1874, xvi, p. 178. 

^ Polak, in ' Wocheubl. der Wiener Aerzte,' 1857, -^o. 44, p. 709. 

7 Palgrave, in 'Union med.,' 1866, No. 20, p. 308. 

^ 'Lancet,' 1869, Jan., p. 44. 

s Cornish, ib., 1871, May, p. 703. 

"'^ Murray, ib., 1878, Nov., p. 699. 

" See Twining, 'Clinical lUustr. of the Diseases of Bengal,' Calcutta, 1835, "> 
p. 432 ; ' Report of Smallpox Commissioner,' Calcutta, 1850; Milroy, in ' Transact, 
of the Epidemiol. Soc.,' 1865, ii, p. 153. 

1- Shortt, in ' Indian Annals of Med. Sc.,' 1858, July, p. 505. 

13 Curran, in ' Dubl. Quart. Journ. of Med. Sc.,' 187 1, Aug., p. loi. 

" Cornish, in 'Madras Quart. Journ. of Med. Sc.,' 1861, July, p. 84; Shortt, 
ib., 1866, July. 

1= Huillet, in 'Arch, de med. Nav.,' 1867, Dec, p. 419. 

16 Cleveland, in 'Madras Quart. Journ. of Med. Sc.,' 1863, Jan., p. 32. 


ticularly Cocliiu ;^ in tlie Bombay Presidency, tlie districts 
of Gujerat and Upper Sind ;" many regions of the North 
West Provinces/ and especially tlie Punjaub, where, accord- 
ing to the statement of De Renzy/ smallpox counts among 
the endemic diseases : in Lahore alone, 7000 persons died of 
it in 1865 in the space of two months.^ In the districts 
more remote from general traffic, such as the Nilghirri 
Hills, the disease appears only at long intervals, but when it 
does come it brings a disastrous epidemic." Similar accounts 
of the severe ravages of the disease come from those parts of 
Lower India that we know most of as regards things medical, 
such as Burmah,''' the peninsula of Malacca,^ and Cochin 
China,^ as well as from many parts of the Indian Archiioelago, 
— Borneo,^° Timor,^^ Amboina,^" Ternate,^^ the Nicobars,^'^ 
and other islands. Within the last ten years, the Dutch 
Government appear to have succeeded in introducing vacci- 
nation more generally and in limiting the disease propor- 
tionately. This has been still more the case in Ceylon, 
where vaccination was introduced by the English authorities 
as early as the beginning of the century ; so that Davy,^" 
writing in 1 821, was able to speak of smallpox as almost 
completely exterminated, while later observers^" have pointed 

' Day, ib., 1861. Oct., p. 213. 

^ Don, iu * Bombay Med. Transact.,' 1840, iii, p. 10. 

' McGregor, 'Observ. on tbe Principal Diseases in the N.W. Provinces of India,' 
Calcutta, 1843, P- 207. 

■* 'Brit. Med. Journ.,' 1874, Sept., p. 269. 

5 Account iu * Philad. Med. Xews,' 1865, p. 63. 

^ Young, in 'Calcutta Med. Transact.,' 1829, iv, p. 6oj Mack ay, in 'Madras 
Quart. Journ. of Med. Sc.,' 1861, July, p. 26. 

' Dawson, in ' Philadel. Med. Examiner,' 1852, May. 

3 Ward, iu ' Edin. Med. and Surg. Journ.,' 1831, July, p. 188; Dick, in 'Army 
Med. Report,' 1873, xv, p. 329. 

3 Ricbaud, 'Arch, de med. nav.,' 1864, May, p. 356; Tbil, ' Remarques sur les 
Maladies de la Cocbin-Cbine,' Paris, 1866, p. t,2i. 

1" Account in 'Arcb. de med. nav.,' 1872, Jan., p. loj Bulwer, in 'Brit. Med. 
Journ./ 1874, May, p. 618. In tiie Brunei country, with 30,000 to 40,000 native 
inhabitants, 4000 died of the disease witbin three months. 

'^ Accouut in 'Arch, de med. nav.,' 1870, July, p. 15. 

'- lb., 1869, Sept., p. 177. 

'^ lb., 1870, March, p. 176. 

" Steen-Bille, 'Reise der Corvette "Galatea" um die Welt,' Leipz., 1852,!, p. 244. 

'5 Davy, 'Account of the Interior of Ceylon,' London, 1821. 

^'' Kiuuis, 'Letter on tbe Advantage of Vaccination, &c.,' Calcutta, 1837; 
Milroy, in 'Transact, of the Epidemiol. Soc.,' 1865, ii, p. 153. 

SMALLP3X. 133 

out that tlie island is mucli better off as regards smallpox than 
tlie mainland adjoining. In China also^, where vaccination 
was introduced in 1805,^ a considerable decrease of the disease 
has shown itself at certain places/ whereas many other 
regions, including Chee-Foo, Shanghai, Peking, and the 
province of Fung-Thian-Foo (in southern Manchooria), where 
vaccination is very imperfectly practised and inoculation 
still in full repute, constitute permanent centres of the disease, 
and have often been ravaged by disastrous epidemics of it.* 
In Corea, Cheval found almost the whole population pock- 
pitted.'* In Japan, where the smallpox is said^ to have 
appeared for the first time in a.d. 736, having been intro- 
duced from Tartary, the efforts of the Dutch to introduce 
vaccination have had small success ; according to all ob- 
servers,^ the disease is diffused everywhere and its ravages 
are often very great. Smallpox reached Siberia for the first 
time in 1630, from the nearest Kussian province,'^ and spread 
thence with great rapidity to the Ostiaks, the Tunguses, the 
Yakuts, and the Samojeds, producing frightful havoc among 
them ; in more recent times also, accounts reach us of the 
disastrous prevalence of the disease among the Samojeds. 
Kamschatka, at the time when Miiller travelled through it 
(beginning of i8th century), was quite free from the malady ; 
according to the account of Cook the disease gained admission 
there for the first time in 1767. 

The continent of Australia, up to 1838, had enjoyed an 
absolute immunity from smallpox ; towards the end of that 

1 Pearson, in 'Calcutta Med. Transact.,' 1833, vi, p. 361. 

2 Arinand, in ' Gaz. med. de Paris,' i860. No. 17, p. 261; Friedel, ' Beitrage 
zur Kenntniss des Klimas und der Krankheiten Ost-Asiens,' Berlin, 1863, 
pp. 106, 122. 

^ Lagarde, in 'Arch, de med. nav.,' 1864, March, p. 190; Cheval, ' Relat. 
d'une campagne . . . au Japon, en Chine, et en Coi-ee,' Montpell., 1868, 
p. 41 ; Watson, in ' Edin. Med. Journ.,' 1869, Nov., p. 430; Morache, in ' Annal. 
d. hyg.,' 1870, Jan., p. 55 ; Dudgeon, in ' Glasg. Med. Journ.,' 1877, July, p. 320. 

* L. c, p. 63. 

= Schmid, in 'New York Med. Record,' 1869, Sept., p. 314. 

6 Friedel, 1. c, p. 22; Account in 'Arch, de med. nav.,' 1866, April, p. 278; 
Cheval, 1. c, p. 31; Potocnik, in 'Arch, de med. nav., 1875, Oct., p. 252 ; 
Wernich, in ' Deutsch. med. Wochenschr.,' 1878, No. 9, p. loi. 

■^ Richter, 'Geschlchte der Med. in Russland,' Moskau, 1817, iii, p. 313. 

8 Schrenk, 'Reise in die Tundren der Samojeden,' Dorpat, 1848, i, p. 546. 

'■> ' Sammlung russicher Geschichte,' v, p. 74 (quoted by Richter, 1. c). 


year, the disease appeared at Sydney/ having been imported 
probably from China ; it lasted, however, only a short time, 
and remained absent from the continent until 1868. In that 
year it Avas introduced into Melbourne by a ship, and again 
it spread only to a slight extent and quickly died out." By 
a rigorous inspection of ships on their arrival, it has been 
found possible to prevent subsequent importations, a notable 
instance of prevention having occurred in 1872.^ Tasmania has 
hitherto quite escaped the disease ;** so also has New Zealand ^ 
where an importation of it in 1872 was prevented by strictly 
isolating a vessel that had arrived with smallpox on board." 
In many of the island groups of Polynesia the disease has 
been found to spread much more widely and to be much 
more destructive than in Australia. Its first appearance was 
in Tahiti, which has repeatedly since its discovery suffered 
from severe epidemics, although it has experienced somewhat 
less of the disease since the introduction of vaccination in 
1843." The Hawaiian Islands were visited by the smallpox 
first in 1853, when a ship brought it from San Francisco to 
Honolulu ; in eight months the disease carried off 8 per 
cent, of the population,^ and continued its ravages in the 
years following, so that the number of the inhabitants was 
much reduced;^ another severe epidemic arose in 1872. 
New Caledonia was quite exempt up to 1859,^° when the 
disease was introduced and has not left the colony again. 
The Marquesas were first visited by it in 1 863 /" the disease 
was brought to Noukahiva by natives returning, at the 

1 Account in ' London Med. Gaz./ 1839, June, p. 477. 

- Rocblitz, ' Arcliiv fiir Dermatologie,' 1872, iv, p. 395. 

^ Account in *Mcd. Times and Gaz.,' 1872, Sept., p. 364. 

^ Milliugen, in ' Calcutta Med. Trans.,' 1836, viii, App. xi ; Hall, in ' Trans, of 
Epidemiol. Soc.,' 1865, ii, pp. 70, 293; Moore, ' Dubl. Journ. of Med. Sc.,' 1874, 
Feb., p. 151. 

^ Thomson, in 'Brit, and For. Med.-Chir. Rev.,' 1855, April; Bourse, 'Arcli. 
de med. nav.,' 1876, March, p. 179. 

® Account in 'Arch, de med. nav.,' 1865, Oct., p. 283. 

' Gulick, in 'New York Journ. of Med./ 1855, March. 

^ Le Boy, ' Relat.' med. d'un voyage dans I'ocean pacifique, &c.,' Paris, i860. 

'•• xYccount in ' Brit. Med. Journ.,' 1872, Oct., p. 474. 

'" Vinson, ' Topogr. med. de la Nouvelle-Caledonie,' Paris, 1 858. 

'1 Charlopin, 'Notes rec. en Caledonie,' Montpell., 1868, p. 22. 

'' 'Lancet,' 1869, May, p. 599; Bruuet, ' La race Polyuesienne, &c.,' Paris, 
1876, p. 34. 


requisition of the Frencli autliorities, from the Chinca Islands, 
wither they had been taken by the Peruvians to dig guano ; 
it spread from that centre with such intensity over the neigh- 
bouring islands that some valleys (Happar, Typee) were 
quite depopulated, while the total population lost, on an 
estimate, about one fourth of its number. Since that time 
vaccination has been introduced by the French authorities. 
On the other hand, some island groups of Polynesia appear 
still to enjoy an absolute immunity from smallpox ; such as 
the Tonya and Fiji Archipelagoes, the Samoa Islands, which 
were quite exempt up to i860 at least,^ and the Gamhier 
group, which Brassac gives as still exempt in 1876.^ 

On Euro'pean soil, the smallpox up to the beginning of this 
century, or to the introduction of vaccination, had been one 
of the most widely distributed, most frequent, and most 
destructive of pestilences. In the southern countries, as we 
have seen, the disease had obtained a firm footing in the 
sixth century, and it appears to have been after that date 
that it penetrated to the northern regions, In the Nether- 
lands the first account of it dates from the tenth century ; 
the chronicles make mention of the death from smallpox of 
the Countess Elfrida in 907, and of Count Arnold of Flanders 
in 961,^ the term " variola^'' occurring in the latter case. In 
Denmark it must have been already prevalent in the thir- 
teenth century ; for Iceland, which was first visited by small- 
pox in 1306, received the infection from Denmark. From 
that date down to recent times, it has been nineteen times 
epidemic in Iceland, undoubtedly reintroduced each time by 
ships, especially Danish. Since the introduction of vaccina- 
tion it has only once, in 18 19, attained a very wide diffu- 
sion; later outbreaks (1836, 1839, and 1840) have been pre- 
vented by strict isolation of the sick,* and Finseu, who writes 
under date 1874, says that he has not seen a single case of 
smallpox within the last ten years.'' In the chronicles of 

' Turner, 'Nineteen Years in Polynesia/ London, 1861, p. 536. 

^ 'Arch, de med. nav.,' 1876, July, p. 12. 

3 'Thijssen, ' Beschouwing der Ziekten in de Nederlanden,' Amsterdam, 1824. 

* Schleisner, ' Island undersogt fra et laegevidenskabeligt synspunkt,' Kjobenh., 
1849, p. 50; Panum, in ' Verhandl. der Wiirzb. Phys.-med. Gesellschaft,* 1852, 
ii, p. 295. 

* ' Jagttagelser angaaende sygdomsforboldene i Island,' Kjobenh., 1874, p. 47 


Ireland the occurrence of the disease is first mentioned iu 
the fifteenth century, but no definite information about epi- 
demics of smallpox there occurs until the eighteenth.^ Iu> 
the Faroe Islands it has been prevalent only twice, the first 
time in 1651/ and again in 1705 ; each time it was imported 
from Denmark and proved very destructive. Since the latter 
date this group of islands has been free from it.'^ Even at 
the present day smallpox takes no inconsiderable place in the 
aggregate sickness of European countries. But since the 
introduction of vaccination, and especially since its legal 
enactment and ofiicial supervision, the occurrence of the dis- 
ease has been confined within tolerably narrow limits. Only 
in large and densely populated towns is the malady kept up 
continuously by successive importations and reproduction of 
the morbid poison. From time to time, as the number of 
susceptible individuals reaches a greater height, it breaks out 
in epidemics which often spread widely ; but the disease in 
Europe has never, since the beginning of the century, 
attained that frightful importance which it had iu past cen- 
turies. How great that importance was will appear in the 
sequel, in the comparative account of the mortality from 
smallpox in the several countries of Europe. 

For the Western Hemisphere the history of smallpox begins 
soon after the landing of the first European immigrants. To 
whatever places they came at length and there settled, every- 
where they carried the disease with them and gave it to the 
natives. But a still more terrible source for America was the 
importatation of negro slaves ; so much so that in after years, 
particularly in South America and the West Indies, not only 
the first appearances of smallpox, but every fresh outbreak of 
it, could be traced to importation from Africa.'^ 

The first outbreak of smallpox in the Western Hemisphere 
took place in the West Indies in 1507, fifteen years after the 
discovery of America, and it was so disastrous that whole 
tribes were extirminated by it. I have not succeeded in 

1 Wylde, in ' Edin. Med. aud Surg. Journ.,' 1S45, April, p. 250. 

2 Debes, in ' Bartholin! acta med.,' Hafn, 1673, i, p. 86. 

3 Mauicus, in ' Bibl. for Ljiger,' 1824, pt. i, p. 32; Panum, 1. c. 

"" Chapman, 'Lectures on the more important Eruptive Fevers,' Philad., 1844; 
Chisholm, ' Essay on the Malignant Pestilential Fever, &c.,' London, 180J, i, p. 60-; 
Desportcs, ' Histoirc des Maladies de S. Domingo,' Paris, 1770, i, p. 89. 

sirALLPOx. 137" 

finding out liow long this epidemic lasted or how far it 
spread. The next information about the disease dates from 
15 1 7, in which year the sickness was imported by the 
Spaniards into Hayti. The subsequent outbreaks in the 
West Indies are chiefly connected^ as has been said, with 
the importation of negro slaves. Thus, as late as 18 19 
it was introduced into Martinique by a slave-ship ;^ and even 
the outbreak of 1851 in Jamaica was connected with the 
ari'ival of free negro labourers from the Gold Coast.^ Gene- 
rally speaking, the visitations of smallpox in the West Indies 
down to recent times have been severe ; thus, in the epidemic 
of 1843 i^ St. Thomas, at least one sixth of the population 
sickened,^ and only those islands where vaccination has found 
somewhat general acceptance, such as Antigua'* and Jamaica,^ 
have enjoyed a comparative immunity. The disease reached 
Mexico for the first time in 1520 with troops from Spain j*^ 
the number of persons swept off in a short time has been esti- 
mated at three millions and a half. There is mention of later 
epidemics of especial severity in the years 1763, i779,and 1797. 
In 1804, vaccination was introduced into Mexico, but only in 
a small way ; so that the country down to the most recent 
times has often had to bear very severe smallpox epidemics.^ 
The Eastern seaboard of the United States was reached 
first in the beginning of the seventeenth century, the 
disease having shown itself in Boston in 1649;^ l^ere also 
vaccination, which was early introduced (1799), put a stop' 
to the sickness in its disastrous forms, and inasmuch as 
the larger part of the interior (Mississippi Valley) was not 
colonised until after the introduction of vaccination, the dis- 

1 Account in 'Nouv. Journ. de Med./ 1819, May, p. 67. 

^ Miller, in ' Med. Times and Gaz.,' 1867, April, p. 441. 

3 Account in * Sundhedskoll. Forhaudl.' for 1844, p. 3. 

■* Nicholson, in ' Transact, of Epidemiol. Soc.,' 1866, iii, p. 48. 

= Seaton, in 'Assoc. Med. Journ.,' 1855, p. 728. 

" Bernardo Diaz, in his ' Hist, verdadera de la conguista de ISTueva Espaiia ' 
(Madrid, 1632), states as an eye-witness: "Y como veniuros en aquel tiempo con 
cortes, y dende a diez meses vino Xarvaez, y truxo un negro Ileno de viruelas; 
et qual las pegd a todos los Indios que habia en un pueblo, que ce decia Cempoala, 
e desde aguel pueblo cundio toda la Xueva-Espaiia, e ovo grande pestilencia." 

7 Compare Strieker, in 'Hamb. Zeitschr. f. Med.,' 1847, xxxiv, p. 525 ; Miiller, 
' Monatsbljitter fiir Med. Statist.,' 1857, No. 6; Jourdanet, ' Le Mexique, &c./ 
Paris, 1S64, p. 406. 

s Brown, in ' Amer, Med. Recorder,' 1829, Jan., p. 50. 


ease there, as in Europe subsequently to vaccination, never 
attained a wide diiiusion among tlie whites.^ On the other 
hand, smallpox made frightful havoc among the Indian 
tribes, following the march of colonisation westward. Thus 
in Kansas it broke out in a destructive form among the 
natives first in 1837,^ and in California in 1850, after the 
arrival of the gold-diggers.^ In the same way, it has in 
more recent times taken an enormous number or victims 
among the Indian population of British Columbia j* in Yan- 
couver's Island, more than a thousand Indians died in the 
winter of 1862-63, and there was considerable anxiety lest 
the whole native population should be cut off.'' It was intro- 
duced first to Greenland from Denmark in 1 733 ; and its 
outbreak was so disastrous there that almost the whole colony 
died. That country has had repeated visitations of the sick- 
ness since then (1800, 1809, and 1851).*' 

Its first appearance, as well as its later outbreaks, on the 
continent of South America, are for the most part due to 
importation of the disease by negro slaves from Africa, and 
this applies particularly to Guiana and Brazil. In Guiana, 
smallpox has occurred but seldom, no doubt by reason of the 
extremely limited traffic in the country ; thus Bajon, during 
a residence of many years in Cayenne, saw only one epi- 
demic (1766), which owed its origin to an importation of 
negToes.''' The malady broke out in 1803 under the same 
circumstances ; Nogen says in his account of this epidemic : 
'' The alarm among the colonists was all the greater that 
this malady is not at all endemic in Guiana, and this 
was its first appearance.''^ The disease first reached 

^ Drake, ' Treatise on the Principal Diseases of the Interior Valley of North 
America,' Pliilad., 1854, ii, p. 565. 

^ Lloyd, in the English transl. of Prince Maximilian's ' Eeise im luuern v. 

2 Praslow, ' Der Staat Californien in med.-geogr. Hinsicht,' Gott., 185;, 

P- 55- 

* Freyman, in 'Arch, fiir wissenschaftl. Kunde Russlands,' 1848, vi, p. 22O. 

* Account in ' Philad. Med. News,' 1863, p. 32. 

" Wendt, ' Efterretninger om Bornekoppor, &c.,' Kjobeuh, 1824, p. 67 ; Lange, 
' Bemaerkn. cm Gronlands sygdomsforhold,' Kjobeuh, 1S63, p. 34. 

' * Nachrichten zur Geschichte von Cayenne.' From the French. Erfurt, 
1 780, ii, p. 56. 

^ ' Revue med.,' 1834, Aug., p. 313. 


Brazil, according to Piso/ iu 1560, and was in like manner 
introduced by negroes ; it has been very prevalent there, 
particularly among the Indians, down to recent times, in spite 
of vaccination, which was introduced in 18 14 but has been 
carried out unquestionably in a very careless and imperfect 
way ; so disastrous has the smallpox been that Tschudi 
speaks of it as the chief scourge of the country." Later 
epidemics as well, such as that of 1834, have always followed 
the arrival of slaveships,^ Smallpox was probably brought 
to the States of the La Plata by the Spaniards, but there is 
nothing accurately known of th.e time of its first occurrence 
there ;* down to recent times it has over and over again 
committed great ravages throughout the country. The same 
is true of Chili, where the disease had been introduced pre- 
vious to 1554,^ also by the Spaniards ; all the chroniclers 
agree iu describing it as the most frightful scourge of the 
inhabitants,*" and on that account, as Fournier states,^ it is 
known to the people as " peste " kut' e^o^r/v. In Pern (in 
Lima particularly) the first epidemic of smallpox is said to have 
taken place in 1 802 (?) ; it is now one of tlie gi-eatest plagues 
of the country, particularly among the negroes and Indians,^ 
notwithstanding that the natives appear to have been 
acquainted with the protective power of vaccine long before 
the advent of Jenner.^ 

' ' De utriusque Lidia) historia natural! et medica,' Amsterd., 1658. 

^ ' Wien. med. Wochenschr.,' 1858, No. 31. An account of the destructive 
ravages of smallpox iu the province of Maranhao is given by Plagge in * Monatsbl. 
fiir Statist./ 1857, No. 10. 

•^ Sigaud, ' Du climat et des maladies du Bresil,' Paris, 1844, 108, 181. 

'' Brunei, ' Observ. topogr. et med. faites dans le Rio-de-la-Plata,' Paris, 1842, 
p. 42. 

5 Coni, in ' Virchow-Hirscli's Jabi'esbericbt,' 1878, ii, p. 46. 

" Poppig, in ' Clarus' Beitriige zur Heilkd.,' 1834, i, p. 526 ; account in ' Arch, 
■de med. nav.,' 1864, Sept., p. 103; Boyd, in ' Edin. Med. Journ.,' 1876, Aug., 
p. 1 10. 

" ' Arch, de med. nav.,' 1874, Sept., p. 148. 

8 Smith in 'Edin. Med. and Surg. Journ.,' 1840, April, p. 333. 

3 Unaune (' Observ. sobre el clima de Lima, &c.,' Lima, 1806) mentions the 
following fact of interest in this connexion : — A negro slave having been vacci- 
nated on the outbreak of the disease in 1802, but without effect, stated, when 
the operation was about to be repeated on him, that he was sure he could never 
take the smallpox as he had got an eruption at the cow-milking in the Andes, 
which, the shepherds had told him, had come from contact with a nodular 
eruption on the cows' udders, and would act as a protection against small- 


§ 36. Influence of Vaccination on the Prevalence of 


However rich tlie medical and historical literature may be 
in accounts of the occurrence of smallpox at various parts of 
the globe ; however clearly the past may bear witness to the 
amount of human life that has been offered up a sacrifice 
to this murderous disease, beside which the loss through the 
bloodiest of wars, or through other severe pestilences such as 
plague and cholera, appears to be infinitesimally small ; and how- 
ever sufficient may be the researches into the present geogra- 
phical distribution of the disease, — still the materials available 
to us are not even in a measure adequate for drawing up a proper 
history of the pestilence in past centuries. It was not its rarity 
but, as Haser justly remarks, actually its every-day occurrence 
that weakened the interest of epidemiographists towards it. 
But we may be all the more easily consoled for this defective 
state of the epidemiological record of smallpox in the pre- 
vaccination era, by the reflection that even a complete nar- 
rative of the smallpox epidemics of that time would have no 
further scientific interest than as enabling us to vindicate the 
importance of vaccination for preventing the disease, or, at 
least, for reducing the mortality caused by it. So far as 
answering that question goes, the materials at our service are 
amply sufficient ; and the question has been already answered 
so often and so thoroughly, particularly in the classical 
reports of the English Board of Health under the editorship 
of John Simon, ^ and in the excellent work of Bohn," that I 
find no occasion to adduce once more the historical proofs 
relating to it. 

That the achievement of Jenner was at once a turning- 
point in the history of smallpox, and a new era in the 
physical Avelfare of mankind ; that the power of the 
pestilence became more and more restricted both in range 
and in severity in proportion as the practice taught by him 

pox. From this statement it follows the disease had been prevalent in Peru 
(at least in the Andes) long before 1802. 

1 'Papers relating to the History and Practice of Vaccination/ London, 1857. 

^ 'Handbuch der Vaccination,' Leipzig, 1875. 


obtained acceptance and careful attention at the Lands of 
various nationalities ; that the disease at the present day, as 
is abundantly shown in the foregoing account of its geo- 
graphical distribution, still bears, in those regions where 
ignorance and prejudice have opposed the adoption of vacci- 
nation or where the carelessness of the authorities has neu- 
tralised its good effects, tho same character for destructiveness 
that meets us in the medical and chronological accounts, and in 
the mortality statistics, of European countries in the pre-vac- 
cination period ; that even to-day we find in the devastation 
of populous districts, and in the uprooting of whole tribes, 
the indications of what this ravaging pestilence could do — 
all this is so thoroughly brought out in the writings I have 
named, that it can bo only folly or stupidity that would seek 
nowadays to minimise or to question the immortal merits of 
Jenner. The foolish attempts made to discredit vaccination 
may be met with the simple but conclusive remark of 
Porter's •} " it will require an immense accumulation of facts, 
more than the world ever saw, to shake our faith in the pro- 
tective influence of vaccination.'' 

The expectations, indeed, which arose out of .Tenner's ori- 
ginal practice for warding off the smallpox have not been 
borne out to the full extent. Experience has taught us that 
the practice required to be widened, that the protective 
power of vaccine was found in many cases to be sufficient 
only for a certain time, that the susceptibility to the morbid 
poison, abrogated by a single vaccination, was in many persons 
restored after a longer or shorter period, and that re-vaccina- 
tion was necessary to give lasting protection. Experience 
also has served to prove that the supervision of vaccination 
by the State, even in those "countries where it was carried 
out according to law, had not been, and even still in part is 
not, administered with the energy that can alone make the 
guarantee perfect.^ It has become clear that this guarantee 

1 ' Amer. Journ. of Med. ?c.,' 1853, Oct., p. 322. 

* Nob to instance the futile efforts of European governments to introduce 
vaccination into their foreign possessions or colonies, many countries in Europe 
furnish the most telling evidence that vaccination and revacciuation are still 
imperfectly carried out. Thus, to quote only a few examples, it is stated by 
Kanzow (' Sanitatsbericht aus dem Eegbz. Potsdam von den Jahren 1869 — 
1874,' Potsdam, 1876, p. 23), in treating of the smallpox epidemic of that 


can be secured only where tlio indifference and prejudice of 
the public, often led astray by false prophets, is met by com- 
pulsory vaccination, and only where this important matter is 
not left to police edicts or to administrative orders, but is 
regulated by statute. The Bavarian Government, not to 
mention others, has given a striking example of what may 
be achieved in this way. 

With the introduction of vaccination into the civilised 
States of Europe, covering a period from 1799 to 1804, a 
remarkable decrease in the amount of smallpox and in the 
mortality caused by it, quickl}- became noticeable ; ^ and thus 

district in 1871-72, that the considerable extension of tlie disease (the mortality 
having been at the rate of 2"j per 1000 of the population) had been much 
helped by the circumstance that the number of persons remaining unvaccinated 
had increased very much ; and, as several physicians unhesitatingly testified, 
those only died of the disease who had never been vaccinated or had been 
vaccinated badly and without effect. The condition of things was no better in 
the other departments of Prussia and in the other States of Germany. Grim- 
shaw (' Dubl. Journ. of Med. Sc.,' 1878, Jan., p. 490) remarks of the Dublin 
epidemic of 1871 that great laxity in carrying oub vaccination had occurred 
there in recent years, and that a wide field for the ravages of the disease had in 
that way been left open. The complaints from France of the neglect of vacci- 
nation of late have been especially strong. Vacher (' Gaz. med. de Paris,' 1871;, 
No. 38, p. 471), in his report on the smallpox epidemic of 1870-71 in France, 
writes : — " It is almost incredible that, seventy- five years after Jenner's discovery > 
one third of the French people should be without the benefit of vaccination ; 
there are departments, such as L'Aveyron and La Corse.where one can count hardly 
more than tweaty vaccinated among one hundred of the inhabitants." Guillon, 
who served in the Franco-Prussian War of 1870-71 as surgeon to a batallion of 
Gardes Mobiles 1158 strong, and had under observation 600 cases of smallpox 
among them, complains in like manner of the extremely defective vaccination 
and revaccination in France, and appends to his report (' Sur une epidemic de 
variole,' Paris, 1871, p. 37) the following note: — "During his enforced stay 
with the Germans, my excellent friend Dr. Jules Petit remarked the almost 
complete immunity which our enemies enjoyed as regards the cjiidemic of 
variola. On his inquiring of the Prussian surgeons the cause of this, they told 
him that the result was exclusively owing to compulsory revaccination." I add 
to this the interesting fact given by Macpherson (' Indian Annals of Med. Sc.,* 
1852, Jan., p. 232) that, in the Presidency of Bengal, at a time when smallpox 
was making frightful ravages among the natives, only 103 cases (with 29 deaths) 
occurred among 84,143 European troops in a space of four years, 11 cases (witli 
I death) among 2970 officers, 26 cases (with 4 deaths) among 7941 soldiers' 
wives, and 26 cases (with 9 deaths) among 9255 soldiers' children. 

^ It has been proved conclusively in the writings above mentioned (the report 
published by the English Medical Department, and the work of I3ohn, p. 289 ff), 
that the introduction of vaccination was not merely an accidental coincidence with 
one of those temporary remissions of the disease which had been often observed 





it came to be believed that tlie enemy had been driven for 
ever from the field. The peace had lasted^ however, o^ily 
some ten or fifteen years^ when the ravaging disease raised 
its head anew. And if its prevalence on European and 
North Amci"ican soil, as well as in all those regions where 
vaccination had found general acceptance, was no longer to 
the extent, and above all of the malignancy, of previous cen- 
turies, yet there were many epidemics, more or less widely 
spread, and sometimes covering a great part of the globe, 
which vividly recalled the tragedies of the past. In the post- 
vaccination epoch, the disease has been most severe and of a 
truly pandemic character during the years from 1868 to 


in previous centuries. I may here remark further that in the history of pestilences 
in Italy hy Corradi (' Annali delle epidemie occorse in Italia/ Bologna) there is not 
a single epidemic of this disease mentioned for the years from 1805 to 181 7, con- 
trasting with the numerous smallpox epidemics of the iSth century. The 
following table, drawn up by Seaton for the English reports, of the mortality 
from smallpox in the various countries of Europe in the pre-vaccination and post- 
vaccination periods, affords very interesting evidence on this point. 


Mean annual mortality from smallpox 


per million population 

Before vaccina- 

After vaccina- 



Before vacciuatioD. 

After vaccination. 

1777 — j8o6 

1807 — 1850 

Lower Austria ... 



1777 — 1806 

1807— 1850 

Upper Austria and 



• .• 

• • • 









1777 — 1806 


Trieste ... 



1777— 1806 

1807 — 1850 




. .. 

Bohemia ... 




Moravia ... 




Austrian Silesia ... 

5,8 1 2 


. . . 








1776 — 1780 

1810— 1850 

East Prussia 




1816— 1850 




1776— 1780 

1810 — 1850 





t8i6 — 1850 






Rhine Province ... 

908 90 

1781— 1805 

1810 — 1850 


3,442 176 


1810 — 1850 


1,774 130 

1774 — 1801 

1810 — 1850 

Sweden ... 

2,050 158 

1751 — 1800 

1801 — 1850 


3,128 286 


1 A tolerably complete survey of the smallpox epidemics of the last fifty years 
is given by Bohn (1. c, pp. 19 ff). Seaton has given (' Report of the Med, 


§ 37. Pekiodicity of Epidemics. 

Not many of the acute infective diseases show in their 
incidence and diffusion so complete an independence of the 
■conditions of climate and soil as smallpox^ which thrives 
equally well wherever its contagion is carried, and wherever 
it finds a population open to its reception and capable of re- 
producing it. It is this last circumstance that explains in 
the most obvious way the seeming 'periodicity in the succes- 
sion of the epidemics at various points, a periodicity which 
had engaged the active attention of the earlier observers both 
before and after vaccination, and has given rise to many 
metaphysical explanations, including the theory of a " con- 
stitutio epidemica variolosa " periodically developing itself. 
The first point that strikes one particularly, in a criticism of 
ttese observations, is that this periodicity in the recurrence 
of smallpox epidemics has presented itself in very various 
ways at the various places of observation. Thus, Werlhof,^ 
after forty years^ experience in Hanover, estimates the interval 
at four to five years, and it is put at the same figure by 
Heineken" for Bremen, and by Gibson^ for the Deccan ; while 
Guys assigns three to four years for Aleppo,^ Hufeland five 
to six years,*^ Holwell, Heymann,^ Dawson,'' Bayfield,*^ and 
others seven to eight years for India, and Strieker sixteen 
years for Mexico.^ All these data are based upon observations 
for very short periods ; the circumstances will look entirely 
different when w^e take account of the epidemic outbreaks 
of the disease at a given place over a longer period and in 
the times before vaccination as well as after it. I content 

•OfScer of the Privy Council, &c., for the Year 1874,' new series, iv, Lond.j 1875, 
p. 51) a detailed account of the great epidemic of 1869-73. 

' ' Disquis. de variolis' in 0pp., Hanover, 1775, p. 477. 

- ' Die Hansestadt Bremen, &c.,' Bremen, 1836, 

•' ' Bombay Med. Transact.,' ii, p. 10. 

•• 'Statistique du Paschalik d'Alep.,' Marseille, 1853, p. 63. 

° ' Bemerk. iibcr die Blattern, &c.,' Leipzig, 1789. 

" 'Versuch einer Darstellung dcr Krankh. in den Tropenlandern,' Wvirzb., 
1855, p. 224. 

^ ' Philad. Med. Examiner,' 1852, May. 

8 ' India Journ. of Med. Sc.,' 1834, i, p. 362. 

" ' Ilamb. Zeitschr. fiir die ges. Med.,' 1847, xxxiv, p. 525. 


myself witli adducing a few examples from the history which 
are especially instructive in this respect. Epidemic out- 
breaks of smallpox occurred as follow : 

At Boston^^ 1649^ 1666, 1678, i6go, 1702, 1721, 173O;, 1752, 
1764, 1776, 1788, 1792; at Philadelphia/ 1808, 1811, 1823, 
1827, 1833, 1841, 1845, 1848, 1851, 1855, i860; at Nancy/ 
1825, 1832, 1841, 1846, 1850 j at Vienna/ 1742, 1745, 1749, 
1757^ 1759; at Breslau/ 1804, 1813, 1823, 1831, 1842, 1851, 
1856, 1863, 1868, 1 87 1. Reunion^ was quite free from smallpox 
for twenty-four years (1827-185 1) and the epidemic of 1851-52 
was followed seven years later by that of 1858-60. In Ice- 
land the disease was prevalent in 1306, 1310^ 1347^ 1380, 
1430, 151 1, 1555, 1574, 1580, 1590, 1616, 1632, 1636, 1655, 
1658, 1671, 1707, 1742, 1762^ 1786, and so on. 

There are, in my opinion^two factors only that determine the 
recurrence of an epidemic of smallpox : on the one hand, the 
necessary number of persons susceptible of the morbid poison, 
and, on the other hand, the introduction of the virus itself. 
In large towns where there is certainly no lack of frequent im- 
portations of the kind, where, in fact, the poison is perennial, 
an epidemic will come about, as Fleischmann assumes for 
Vienna,'^ whenever there is a sufficiently large number of 
persons capable of infection, that is to say, in our post- vacci- 
nation times, unvaccinated ; and therefore four or five years 
may be regarded as sufficient for Vienna. But there can be no 
rule of the kind whenever the practice of vaccination is carried 
out at all efficiently. Forster,^ who forms his estimate in 
the same way as Fleischmann, puts the frequency of epidemic 
recurrences at Dresden at seven to eight years ; but, for those 
places where the morbid poison dies out at the end of an 
epidemic, it stands to reason that the disease cannot reappear 
until new virus is imported, and under these circumstances 
there can be absolutely no question of regularity in the 

Curtis, in ' Transact, of the Amer. Med. Assoc.,' 185 1, ii, p. 487. 
- Jewell, in 'Amer. Journ. of Med. Sc.,' 1862, April, p. 378. 
^ Simonin, ' Rechercli. topogr. et uied. sur Nancy,' Nancy, 1854, p. 244. 
^ Plenciz, 'Tract, de variolis,' Vienna, 1762, p. 49. 
5 Pastau, in 'Arch, fiir klin. Med.,' 1873, xii, p. 112. 
^ Azema, 1. c. 

" ' Jahrb. fiir Kinderheilkunde,' 1870, iii, p. 456. 
* lb., 1868, i, p. 121. 



recurrence of the sickness. This is naturally best seen at 
those places which are remote from traffic and much more 
rarely infected than places lying in the track of commerce. 
Popper^ for Prague^ and Hagenbach" for Basely completely 
dismiss the idea of regularity in the recurrence of smallpox 
epidemics, and they are perfectly justified in doing so, upon 
their data. 

§ 38. Influence op Season. 

Although the occurrence of smallpox is seen to be in 
general independent of conditions of climate, still the season 
of the year has a marked influence upon the amount of the 
sickness or upon its epidemic diffusion. Razes^ had already 
arrived at the conviction, from his experiences in Arabia, 
that epidemics of smallpox occur at all seasons, but that they 
mostly begin towards the end of autumn and in the early 
spring, or in the cold season. Opinions completely agreeing 
therewith have been expressed by Pruner,* who adds that 
" the hot months in the latitude of Cairo, ordinarily from 
June to October, are for the most part equally little suited 
for the development of smallpox as for the plague ;" and by 
Rigler^ for Constantinople, where smallpox appears usually 
on the approach of winter, continues till spring, and dies 
out in the hot season ; by Ferriui for Tunis, where the dis- 
ease prevails most frequently in spring ; by Rendu^ for Brazil, 
where the time for the prevalence of the disease falls in the 
months from October to December (that is, in spring) ; by 
Poppig^ for Chili, where the epidemic is at its height in the 
months from July to November (end of winter and spring) ; 
and by Pearson,^ Morache,^ and Lagarde^° for China. 

1 ' Zeitscbrift fiir Epidemiol.,' 1876, ii, p. 222. 

2 ' Jahi-l). fiir KinderUkd.,' 1875, ix, p. 62. 

s ' Liber de variolis,' cap. ii, after tbe translation by Mead. 0pp. Naples, 

•» L. c, p. 128. 
5 L c, ii, p. 30. 

<> ' Etud. topogr. et med. Bur le Bresi!,' Paris, 1848, p. 66. 

7 L. c., p. 526. 

8 L. c., p. 361. 

9 L. c. 
w L. c. 



Tlie following table gives the details as to the amount of 
sickness in India in the various seasons : 

Deaths from Smallpox. 













> tj 00 September. 























The greatest prevalence, accordingly, falls here in the cold 
season corresponding to the spring of temperate latitudes, 
and that applies to the whole of Bengal/ the Madras Presi- 
dency/ the districts belonging to the North-West Provinces/ 
and to. the Punjaub.^ 

The frequency of the disease in the several seasons within 
temperate latitudes shows an almost complete correspondence 
with the above. The following table gives the time when 
the epidemic was at its height in ninety-nine outbreaks on 
European or North- American soil, of which there are accu- 
rate data. 

October to January. . . 3 
October to Marcli ... 2 
November toDecember 2 
November to January 3 , 
December to January 3 
December to March. , , 4 
January to March ... 8 
February to March... 2 

Autumn and Winter 10' 



' 'Report of the Smallpox Commissioner/ Calcutta, 1850. 
^ Morebead, ' Clinical Researches on Diseases in India/ Lond., 1856, i, p. 317. 
The numbers are the monthly proportion in each hundred fatal cases. 
3 Macpherson, in ' Med. Times and Gaz.,' 1873, July, p. 31. 
* Maclean, in ' Calcutta Med. Transact./ v, p. 399. 
^ Macpherson, Cornish, 11. cc; Day, in ' Madras Quart. Journ.,' 1861, Oct., 

p. 213- 

^ McGregor, Macpherson, 11. cc. 

^ De Renzy, in 'Brit. Med. Journ./ 1871, Sept., p. 264. 



December to May ... 4"^ 

January to April 7 j 

January to June i }■ Winter and Spring 16 

Febniary to April ... 3 
February to June ... i J 
Marcli to April 4 

» Cold Season ... 67- 

March to May 9 

Marcli to June 7 

April to May 4 

April to September... 2 

May to June 2 

May to August 3 

JunetoJuly 6 

June to August 7 

August to September i 
August to October ... 6 . 
September to October 2 
October to November 3 



Spring and Summer 

Summer 14 

Summer and Autumn 6 
Autumn n 


> Warm Season. . . 3? 

This result is borne out by the following table, in which 
I have put together the number of deaths from smallpox 
within a certain time, in various counti'ies or places in the 
temperate zone, according to the months or quarters of the 








r ^ 

c > 

r ^ 

















Danzig . . 












136 135 

Breslau . . 


199' 144 









128 147 

Berlin . . 


96 125 




192 X41 




82 94 



2005 2501 




2064 1361 




715 1172 

Paris . . . 


336 224 







832; 983I 639' 415 

Paris . . . 


569 517 







342 418 506 701 

Paris . . . 


174 293 







700 13611722 1837 

Milan . . 


149 83 




388 451 



953 961, 5901 



832, 615 




122 35 




502 1 104 





4681 3980 





>^ i 

V , 


I .. J V ; 1 























Sweden . . 






On the other hand, the character or severity of the disease 
appears to be quite uninfluenced by the season and the kind 
of w^cathcr. Sydenham, indeed, thought himself justified in 


concluding from his observations, made in the London epi- 
demics of 1667-69 and 1673-75, that smallpox ran an espe- 
cially severe course in the high temperature of summer, and 
Stoll^ afterwards expressed the same opinion. However, as 
Van Swieten was the first to remark,^ there are numerous 
exceptions to this rule, and his presumption that the severity of 
the epidemic depended on other things than the influences of 
the season, has been borne out by subsequent experiences, 
such as those of the very severe winter epidemics of 1666 in 
Paris,^ 1840 in Semecourt,* 1847^ and 1869-70 in Paris,'' 1726 
in York,^ 1761 in Gottingen,^ 1754 in Liineburg,^ 1798 in 
Cracow,^^ 1 80 1 in Treves,^^ and of 1806 in Helmstiidt.^" 
Pearson, in fact, states'^^ that in China the disease is the 
more severe the earlier in the year the epidemic breaks out, 
or the lower the temperature at the time of the outbreak. 

§ 39. The Specific Poison op Smallpox. 

That smallpox owes its origin to a specific poison, that 
this poison is capable of reproduction, and is therefore an 
organic body, and that it can at once exert its power in the 
form in which it is eliminated from the sick person, wherein 
it bears the clear mark of a contagious morbid poison — all 
•this hardly requires to be proved, even although the investi- 
gations'^* that have been directed to the detection of the 

' ' Eatio medendi in nosoc.,' Viiidob., ii, 211. 
^ ' Comment, in Boerhaave Aphorismos,' Lugd. Bat., 1772, v, 5. 
^ Lamotte, 'Traite complet de chirurgie,' Paris, 1722, iii, p. 383. 
■1 Bastien, in ' Travaux de la Soc. des Sc. med. du departem. de la Moselle,' 
.1841-43, Metz, 1843, p. 2. 

° Matice, in ' Gaz. med. de Paris,' 1847, Oct., p. 797. 
^ Besnier, in 'Union med.,' 1870. 
^ Wintringham, 'Comment, nosol.,' Berl,, 1791, p. 85. 
" Heusler, ' Observ. de morb. variol.,' Gott., 1762. 
^ Lentin, 'Beitrage zur Arzneiw.,' Leipzig, 1797, i, p. 223. 
Account in 'Med. Nationalztg.,' 1798, p. 666. 
Burchardt, in 'Med. Annalen,' 1802, Correspoudbl., 177. 
^'Remer, in 'Hufeland's Journ.,' 181 5, xl, pt. 4, p. 32. 
' Calcutta Med. Transact.,' vi, 1. c. 

Keber, in 'Vircbow's Arcbiv,' 1864, vol. 42, p. 112; Cbauveau, in 'Gaz. 
med. de Paris,' 1868, p. 140; Salisbury, ' Microscopic Examinations of Blood 
.and Vegetations found in Variola,' &c.. New York, 1868 ; Weigert, in ' Centralbl. 


poison have either had very doubtful results or no result 
at all. 

As to the native habitat of the smallpox poison there is 
still, as we have seen at the commencement of this inquiry, 
much obscurity. The assumption that it is coextensive with 
the distribution of the disease is contradicted by the evidence 
adduced above, that large portions of the globe, the whole 
Western Hemisphere, the Continent of Australia, and Poly- 
nesia, have enjoyed immunity from smallpox until such time 
as the disease was imported thither from other points, and 
that many of these regions had not lost that immunity until 
quite recent times. From its native foci, the morbid poison 
has been spread gradually, and doubtless repeatedly, by sick 
persons or by objects to which it clung, over the greater 
part of the globe, and thereby the disease has been diffused 
in ever-widening circles. Contrasting, however, with other 
morbid poisons, such as those of cholera, typhus, and yellow 
fever, that retain the power of reproduction for only a short 
time away from their native focus, the poison of smallpox 
appears able to survive outside its habitat so long as it finds 
individuals who are susceptible to it, or who offer to the 
poison a suitable soil for its reproduction. It is when that 
nutrient soil fails that the virus perishes, or loses its potency 
and capacity for increase. Evidence of this is furnished by 
the behaviour of the disease, as above described, in regions 
such as Iceland, the Faroe Islands, Guiana, and the like, which 
are situated remote from the great lines of traffic, or such as 
Reunion, the West Indies, and the Australian continent, which 
are connected with the centres of commerce by the sea-road 
only j in those regions the introduction of the morbid poison 
takes place much more rarely than by the quicker way of land 
traffic, and there are accordingly decades intervening between 
the various epidemic outbreaks of smallpox, during which 
the country enjoys a complete exemption from the disease. 
It is otherwise in the great centres of intercourse, where the 
morbid poison is continuously provided ^vith a suitable 

dcr med. Wiss.,' 1871, No. 391, ' Anat, Beitriige ziir Lehre von den Pocken,' 
2 pts., Breslau, 1874 and 1875, and in ' Deutsche Zeitsclir. fiir pract. Med.,' 1874, 
No. 43; Zulzer, in ' Berl. klin. Wocb./ 1872, No. 51; Cobu, in * Virchow's 
Archiv,' J872, vol. 55, p. 229. 


*' nutrient soil" in the fluctuating population, wliere the 
disease therefore continues to flourish, and will attain 
epidemic diffusion whenever predisposed persons are massed 
together more than usual, and more particularly when there 
are active movements amongst the population. In fact, 
these are just the centres from which all the far-reaching 
epidemics take their start. 

§ 40. Individual Susceptibility to the Poison. 

The single factor, then, that determines the development 
of the sickness, besides the presence of the infecting sub- 
stance, is a population susceptible to it ; and this suscepti- 
bility to the poison of smallpox^ is one that extends to the 
whole of mankind. Experience shows, however, that the 
coloured races, and especially the negro race, are, ceteris 
paribus, in greater risk from smallpox than the whites. 

" The members of the human family," says Pruner,^ " that 
are most susceptible to the poison of smallpox are the negroes. 
Not only in their native lands, but in other parts of the 
world as well, they are the first to succumb to the 
epidemic influence, and also the last. It is no unusual 
thing to see negroes attacked by smallpox as soon as they 
arx'ive in Egypt (where they certainly change their way of 
living as well as the climate) and that, too, at times when the 
disease does not exist among the other inhabitants." 
Similar statements, equally emphatic as to the increased inten- 
sity of the disease in the negro, are made by Daniell" for 
the West Coast of Africa, for Martinique by Rufz,^ (according 
to his observations in the epidemics of 1836-37 and 1848-50) 
for Cura^ao,^ for Cayenfie^ by Bajon, and for Peru.^ In 
Boston there died in the epidemics of 1649- 1792, or at a time 
when there was no question of protection by vaccination, 
10-8 per cent, of white patients and 237 per cent, of black.'^ 

' L. C, p. 120. 

* L, c, p. 41. 

2 ' Arch, de med. nav.,' 1869, Aug., p. 137. 

■^ Account in 'NcderL Tijdschr. voor Geneesk,' 1862, vi, p. 592. 

* L. c, p. 56. 

fi ' Arch, de med. nav.,' 1864, Sept., p. 188. 
Shattock, in ' Amer. Journ. of Med. Sc.,' 1841, April, p. 372. 


In the epidemic of 1850 at Baltimore, tlie proportion of 
deaths among 10,000 white inhabitants was 8"i, and among 
negroes 14*5.^ 

§ 41. Diffusion op the Morbid Poison. 

The dispersion of the morhid poison takes place either by 
the smallpox patients themselves, or through the medium 
of other persons, or of articles to which it clings. It has 
been conclusively proved by very numerous and unambiguous 
observations that an atmosphere of smallpox poison develops 
around the sick, especially when they are crowded in close 
rooms ; or, in other words, that the air may become a carrier 
of the contagion, so that the latter can be spread by the 
atmospheric currents within a small range. There is cer- 
tainly no mathematical expression to be found for the extent 
of that range ; at the utmost, it extends no farther than the 
immediate surroundings of the sick, and the smallpox wave 
of Cornish,^ which follows the direction of the east wind and 
determines the progress of the disease in India from east to 
west, is to be considered an idle fancy, all the more so that no 
such constant procession of smallpox has been observed in 
India or elsewhere. 

§ 42. Eelation to Chicken-pox. 

As it required the experience of several centuries before 
the specific nature of smallpox was recognised by physicians, 
it is not surprising that a still longer time elapsed before we 
learned to distinguish between variola and varicella. There 
are, indeed, indications in Eazes,^ Avicenna,* and others of 
the early chroniclers of smallpox, that they had seen vari- 
cella as well as variola ; and we find more precise state- 
ments on the latter disease in Ingrassias,^ Guidi,^ and Eive- 

' Frick, ib., 1855, Oct., p. 326. 

^ ' Lancet,' 1871, May, p. 703. 

3 L. c, cap. 70. 

•» 'Canon,' lib. iv, fen. i, tract, iv, cap. 6, ed Venet., 1564, ii, 71, 

' ' De tumoribus praeter naturam tract.,' Neapoli, 1533, p. 194. 

•^ ' Ars univ. med.,' Venet., 1596, ii, lib. 13, cap. 6. 


rius'^ of the sixteenth century, and in Sennert,^ Diemerbroek/ 
and others of the seventeenth. But the merit of recognising 
and describing the characteristic features of varicella belongs 
to Heberdcn/ whose statements about the " chicken-pox " in 
England were followed by accounts of the same in France by 
Hatte ;^ while in Germany valuable facts about varicella and 
its relation to variola were furnished more especially by 
Heim.*' The question of that relationship, whether it be one 
of identity or of specific difference between the two forms of 
disease, lies outside the limits of my task. In favour of the 
latter view,, there are many data before us bringing out the fact 
that the geographical distribution of varicella as an endemic 
disease extends much farther than that of variola, that it was 
known in several parts of the world before the introduction 
of smallpox — at the Cape, in the southern territories of South 
America, and on the Australian continent — and that in after 
times it has continued, not unfrequently in epidemic form, 
to retain the distinctively mild character of its symptoms, 
altogether irrespective of importations of smallpox from time 
to time at long intervals, or of the introduction of vaccina- 

' ' Method, curand. febr.,' sect, iii, cap. iii. ' Haq. Conist.,' 165 1, p. 154. 

'De febribus/ lib. iv, cap. 12. 
3 ' De variolis et morbillis/ cap. ii. 

■* 'Med. Trans, of the College of Physicians,' i, Lend., 1767, p. 427, and 
Comment, de morb. hist.,' cap. 69, ed. Lips., 1831, p. 229. 
^ 'La verolette ou petite verole volante,' Paris, 1759. 
* Horn's 'Arch, fiir med. Erfahr,' 1809, x, p. 183. 




§ 43. Old Yiews op '' Moebilli :" the History Defective. 

In the writings of tlie Arabian physicians,^ to whom we 
owe the first scientific account of smallpox, reference is at 
the same time made to still another form of acute exanthem 
under the name of " hasbah/' which was regarded by these 
observers as a modification of smallpox." The same disease, 
always in association "with smallpox, is mentioned also by 
the physicians of the middle ages under the various designa- 
tions of morbilli,^ rubeola,"^ rossalia, rossania, rosagia,^ and 
the like, as well as under the colloquial names of ^' fersa " or 
^^ sofersa ^-"^ (Milanese), "mesles,"'' afterwards '^ measles ^^ 
(English), corresponding to the German " maal," and 
'^masern^^ (Grerman), the Sanscrit masura (^^ spots ^'). The 
few casual references to this disease in the Arabian physi- 

' EazeSj in ' Liber de variolis et moibillis,' also in ' Continens,' lib. xviii, cap. 
viii, Brix., i486, fol. Bl. viii (besides the morbilli, thei'e is mention also of 
exanthems under the names of " blacciae " and " lenticula ") ; further, in ' De 
re medica,' lib. x, cap. xviii (0pp. minor, Basil, 1544, p. 304), and in lib. 
division., cap. clix (0pp. e. c. 444); Ali Abbas, 'Liber theoi'.,' sermo viii, cap. 14, 
and ' Liber pract.,' sermo iii, cap. i (here the disease is named rubeola) ; Avicenna, 
' Canon,' lib. iv, fen. i, tract, iv, cap. 8 j Avenzoar, lib. ii, tract, vii, cap. ii. 

- Thus it is stated in Aviceuna : " Scias quod morbillus omuis est variola 
cholerica, et non est differentia inter ea ambo in plurimo reliquarum disposi- 
tionum, nisi quod morbillus est cholericus." 

^ Diminutive of morbus. 

■* Occurring only in the translation of the work of Ali Abbas (see previous 

^ In Concorregio, ' Practica de variolis et morbillis,' in ' Summula de curis 
febrium/ Venet., 1521, fol. 938. 

•^ In Michael Scotus, ' De procreatione et hominis phisionomia,' cap. x j com- 
pare Gruner, ' De variolis ct morbillis fragmenta,' Jena, 1 790, p. ^^. 

' Job. Anglicus, 'Praxis med,' Aug. Viudel, 1595, p. 1041. 


cians do not go far towai'ds characterisiug it, or towards 
deciding for us to what known forms of disease tlie " mor- 
billi " correspond. In like manner, the Arabistic writings, 
which closely follow the Arabian writers, omissions and all, 
afford us no satisfactory information as to what wo are to 
understand under " morbilli.'' Only now and then are indi- 
vidual symptoms mentioned, such as redness, flow of tears, 
throat affection, and the like, while the exanthem itself is 
described as spotted, papular, or vesicular. It is probable 
that we have here to deal with various exauthematous dis- 
eases ; chiefly with scarlet fever and measles, but more par- 
ticularly with scarlet fever, as we may infer from the state- 
ment made by several observers that the " morbilli '' were as 
dangerous as smallpox, and often even more dangerous. 

In the sixteenth century the views of physicians upon the 
acute exanthematous diseases had cleared up, so far, at least, 
as to recognise in the disease called " morbilli," or " rosalia," 
a morbid process different from that of smallpox. But under 
'' morbilli " they still comprised measles and scarlet fever as 
being one and the same process,"^ and we meet with this 
obscurity as late as the seventeenth century, even after 
Sennert, Doring, Sydenham, and others had rightly dis- 
cerned and taught the peculiarities of scarlet fever (first called 
" febris scarlatina " by Sydenham) ; so that even Morton, not 
to mention others, remarks in speaking of this disease :" 
" Hunc morbum prorsus eundem esse cum morbillis censeo,^' 
and adds : " exulet igitur per me e censu morborum haecce 
febris, nisi cuiquam ' morbillorum confluentium ' titulo eum 
designare in posterum visum fuerit." 

From the facts here stated we may conclude so much at 
least as to the history of measles in past centuries, that the 
disease was in all probability widely diffused over Asiatic and 
European soil during the middle ages ; and it has retained 
that position as a sickness of the people in the centuries 
following. In the eighteenth century, by which time physi- 

' A tolerably clear description of the rash of measles is given by the Roman 
physician. Prosper Marziani in his commentary on the ' Libri Epidemior.' of 
Hippocrates, Venet., 1652, p. 744. See Corradi, 'Anuali delle epid. occ. in 
Italia,' parte iii, Bologna, 1870, p. 53. 

* ' Pyretologia,' cap. v, Genev., 1696, p. 28. 


cians liad learned to recognise the peculiarities o£ the disease 
and to distinguish it from other forms of exantliem, we find 
many reports of more or less extensive epidemics of measles 
at numerous points in the Eastern and Western Hemispheres. 
At the present day the area of its distribution may be taken 
to extend over the whole habitable globe. The question of 
the native seat of measles baffles all research ; the history 
teaches us, as will appear in the sequel, this much at least, 
that the sickness has not had a fresh origin at every point 
where it has occurred, that it has issued, and probably still 
issues, from certain centres which cannot be specified more 
particularly, and that the wider diffusion of the disease from 
these native foci, into regions nearer or more remote, depends 
upon a transporting of the morbid poison, which, like that of 
smallpox, can survive outside its habitat so long as there are 
found susceptible individuals, affording to the poison a soil 
adapted for its reproduction, while it perishes if there be no 
gi^ound on which to reproduce itself. 

§ 44. Peesent Geographical Distribuution. 

In Europe, both continental and insular, the distribution 
■of measles reaches from the shores of the Mediterranean to 
the regions of the extreme north, which, if seldom visited, 
have still not been altogether exempt. In the Faroe Islands^ 
the disease has been prevalent four times up to tlie present, 
first in 1 781, then in 1846, again in 1862, but only to a slight 
extent, and lastly in 1875 ; it is proved to have been on 
every occasion imported, the last time from Shetland. Four 
epidemics have been observed hitherto in Iceland,^ in 1664, 
1694, 1846, and 1868/ these have originated in the same 
way as in Faroe, and so also have the numerous outbreaks of 
the sickness in La'pland (the last of them in 1852'^). In the 

' Schleisner, 'Island,' p. 51; Hjalteliu, iu ' Dobell's Reports,' Lond., 1870, 
p. 283. 

^ Maiiicus, ' Bibl. for Liigcr,' 1824, i, p. 32 ; Panum, il)., 1847, i, p. 319, and in 
•* Vircliow's Archiv,' i, p. 4925 Madseu, ' Suudhets-Colleg. Aarshcretuiug for 
1876,' p. 572. 

3 [There was a fifth in 1882.] 

'' Report in 'Suudhets-Colleg. Beriittelse,' 1S52, p. 30. 


intervals of tlie epidemic outbreaks, wliicli were all traceable 
to importation, those countries have been quite free from 
measles. In the countries of Southern Europe, such as 
Roumania,^ Turkey," and Greece,^ the disease is prevalent to the 
same extent as in the other parts of the continent. Similar 
accounts of measles universally diffused and often coming to 
an outbreak, come fi'om all the countries of Asia, from Asia 
Minor,''' the Caucasus,^ Syria and Blesoj^otamia,^ Persia,'^ and 
Arabia ;^ from all the provinces of British Inclia^ from the 
East Indian Archipelago^^ from Further India^^ China,^^ and 
Japan^^ from all those regions of Africa of which we have 
any medical knowledge, such as Egypt,^^ Ahyssinia,^^ Ttmis,^^ 

' Barasch, ' Wien. med. Wocbenschr.,' 1855, No. 36; Leconte, 'Consider, sur 
la pathol. des prov. du Bas-Danube,' Monfcp., 1869, p. 45. 

* Rigler, 'Die Tiirkei,' &c., ii, p. 26; Beyran, ' Gaz. med. de Paris,' 1854, No. 
22, p. 342. 

3 Olympics, 'Bayr. med. Correspondenzbl.,' 1840, No. 12. 

4 West, 'New York Med. Record,' 1869, March, p. 27. 
^ Liebau, 'Petersb. med. Jahrb.,' 1866, xi, p. 281. 

" Tobler, 'Med. Topogr. vou Jerusalem,' Berl., 1855, p. 46 ; Guys, ' Statist, 
du Paschalik d'Alep.,' Marseille, 1853, p. 63; Floyd, 'Lancet,' 1843, ii, p. 4; 
Robertson, 'Edin. Med. and Surg. Journ.,' 1843, July, p. 57. 

7 Polack, ' Wocbenbl. der Wien. Aerzte,' 1857, p. 721. 

s Palgrave, ' Union med.,' 1866, No. 20, p. 308. 

' Twining ('Clin. Illustr,' ii, p. 432) for Bengal; Cornisb (' Madr. Quart. 
Journ. of Med. Sc.,' 1861, July, p. 84) and Shortt (ib., 1866, April, p. 221) for 
the Madras Presidency ; Kinnis (' Edinb. Med. and Surg. Journ.,' 185 1, April, 
p. 316) and Morehead (' Clin. Researches,' i, p. 329) for the Bombay Presidency ; 
Don ('Bombay Med. Transact.,' 1837, i'"' P- 1°) ^°^' Sindj McGregor ('Diseases 
... in the N.W. Prov. of India,' p. 213) and Evans (Edinb. Med. Journ.,' 1855, 
Aug., p. 175) for the N.W. Provinces; Ireland (ib., 1863, Jan., p. 613) and 
Curran ('Dubl. Quart. Journ.,' 1871, May, p. 311) for the slopes of the Hima- 
laya,- Davy (' Account of Ceylon') for Ceylon; and various others. 

''' Waitz, ' On Diseases incidental to Children in Hot Climates,' Bonn, 1843, 
p. 257 ; Heimann, ' Krankheiten in den Tropenliindcrn,' p. 223 ; Van Leant, in 
'Arch, de med. nav.,' 1867, Oct., p. 250, 1868, Sept., p. 164, 1872, Jan., p. 22 ; 
Taulier, ib., 1877, Dec, p. 401. 

" Breton (' Consider, sur la guerison des plaies chirurg. chez les Annamites,' 
Paris, 1876, p. 10) for Cochin China, but said by this author to be rare there. 

'2 Pearson, in ' Calcutta Med. Transact.,' 1833, vi, p. 362 ; Morache, in ' Anna!, 
d'hyg.,' 1870, Jan., p. 25 ; Dudgeon, in ' Glasg. Med. Journ.,' 1877, July, p. 328. 

'3 Gaigneron, in ' Arch, de med. nov.,' 1866, April, p. 279. 

'^ Pruner, 'Krankheiten des Orients,' p. 122; Hartmann, ' Skizzen des Nil- 

^ Blanc, in 'Gaz. bebd. de med.,' 1874, No. 22, p. 349. 

1® Eerrini, ' Sul clima di Tuuisi,' p. 153. 


Algiers^ Senegamhia," the West Coast of Africa,^ the Ca'pe^ 
Madagascar,^ Mauritius,^ and Reunion^ Even the most iso- 
lated parts of tlie world, like St. Selena, have not been 
exempt from measles/ although in the reports from that 
island, up to date, it is admitted by everyone that the disease 
had not occurred there since 1807. 

Measles reached the Western Hemisphere soon after the 
arrival of the first European settlers, its first appearance 
being in the East Coast States of the Union ; it afterwards 
followed the movement of colonists westwards, showing itself 
in the interior or Mississippi Valley, where the disease spread 
quickly throughout Kentucky and Ohio.° The northern and 
western regions of North America had escaped down to 
recent times; the disease appeared first in Oregon^^ in 1829, 
and in California^^ in 1846, and in that year it was imported 
from the south into Hudson's Bay Territory, where it com- 
mitted frightful ravages among the Indians. ^^ Measles does 
not appear to have occurred at all in Greenland down to 
1864 -^^ whether it has occurred subsequently, I have not 
learned. There is no information as to the time of its first 
appearance in Mexico in Central America, or in the West 
Indies ; it would appear from the accounts from these regions 
a,t the end of last century and beginning of this, that measles 

' Guyon, in ' Gaz. med. de Paris,' 1839, ^o- 4^3 1842, No. 34, p. 536; Barth- 
erand, 'Med. des Arabesj' Gaucher, in 'Gaz. ined. de I'Algerie,' 1869, No. 3, 
feuill. p. 34- 

^ Gautliier, ' Endemies an Senegal,' p. IS ; Chassaniol, in ' Arch, de med. nav.,' 
1865, May, p. 506. 

3 Daniel], in ' Dubl. Journ. of Med. Sc.,' 1852, Aug.; Mannerot, 'Malad. 
endem. a Gaboun,' p. 40. 

■* Black, in ' Edln. Med. and Surg. Journ.,' 1853, April, p. 266; Scherzer, in 
'Zeitschr. der Wiener Aerzte,' 1S58, No. 11, p. 166 j Egan, in ' Med. Times and 
Gaz.,' 1873, June, p. 681, 1877, Sept., p. 355. 

5 Davidson, in ' Med. Times and Gaz.,' 1868, Dec, p. 646. 

^ Report in 'Lancet,' 1875, June, p. 865. 

^ Dutroulau, ' Traite des malad. des Europeens dans les pays chauds,' Paris, 
1861, p. 51. 

** Lesson, 'Voyage med. autour du monde,' Paris, 1829, p. 149; McRitcbie, in 
'Calcutta Med. Transact.,' 1835, ^'i''> -'^PP- xxix. 

^ ' Drake, ' Diseases of the Valley of North America,' ii, p. 586. 

"' Moses, ' Amer. Journ. of Med. Sc.,' 1855, Jan., p. 38. 

" King, ib., 1853, April, p. 389. 

'- Smellie, ' Monthly Journ. of Med. Sc.,' 1846, Dec, p. 413. 

12 Lange, ' Gronlands Syzdomsforhold,' p. 37. 


was on tlie wliole a rare disease, the epidemics being separated 
from one another by intervals often of twenty or thirty years, 
and the recurrence each time due to a fresh importation.^ 

In Brazil, measles appeared for the first time in the six- 
teenth century, coincidently with smallpox.^ The disease is 
now universally distributed there and often epidemic. So 
also in the Biver Plate States,^ and in Chili^ and Peru} 

The disease was introduced into Australia in recent times. 
As far as the data before us justify a conclusion, it came 
first to the Haivaiian Islands in i84§,^ and in 1854 to 
the Australian continent, whence it was imported the same 
year into Tasmania^ and Neiv Zealand} Since that time, 
it has been repeatedly epidemic on that continent, as well as 
in several groups of islands, such as Tahiti,^ the Marquesas,^° 
and the Fiji Islands}^ Up to 1858 New Caledonia had 
escaped altogether,'- and the latest medical reports from that 
colony by Charlopin, De Rochas, and others make no mention 
of measles. 

1 See the accounts, for Mexico, by Strieker (' Hamb. Zeitschr. fiir Med.,' 34, 
p. 529), Porter (' Amer. Jourii. of Med. Sc.,' 1853, Oct., p. 321), Bouffier ('Arch, 
de med. nav.,' 1865, May, p. 533) and Heinemann (' Vircliow's Arcbiv,' 1873, 
vol. 58, p. 161); for Honduras by Hamilton (' Dubl. Quart. Journ.,' 1863, Aug., 
p. 105); for Costa Rica by Scbwalbe (•Arcbiv fiir klin. Med.,' 1875, xv, p. 344; 
for the West Indies by Chisbolm (' Essay on the Malignant Pestil. Fever, &c.,' 
London, 1801, i, p. 61), Hunter ('Observ. on the Diseases of the Army in 
Jamaica,' German trans., Leip., 1792, p. 225) and Rufz (' Gaz. med. de Paris/ 
1857, No. 34, p. 532). 

" Sigaud, 'Maladies du Eresil,'pp. iii, 200, 373 ; Rendu, 'Etudes med. sur le 
Bresil,' p. 66. 

^ Brunei, 'Observ. med., &c.,' p. 37; Dupont, 'Observ. med. sur la Cote 
orientale d'Amerique,' Montpell., 1868, p. 14. Mastermann, in ' Dobell's Reports,' 
Lond., 1870, p. 382, gives an account of the disastrous epidemic of measles in 
the National Army of Paraguay dudng the Brazilian War, 

■* Account in 'Arch, de med. nav.,' 1864, Aug., p. 103 ; Boyd, in ' Edin. Med. 
Journ.,' 1876, Aug., p. no. 

^ Tschudi, in 'Oest. med. Woehenschr.,' 1846, p. 729; Smith, in 'Edin. Med. 
and Surg. Journ.,' 1840, April, p. 335 ; account in 'Arch, de med. nav.,' 1864, 
Sept., p. 188. 

s Gulick, in ' New York Journ. of Med.,' 1855, March. 

7 Hall, in 'Transact, of the Epidemiol. Soc.,' 1865, ii, p. 70. 

8 Tuke, in 'Edin. Med. Journ.,' 1864, Feb., p. 721. 
8 Dutroulau, ' Traite,' p. 57. 

'0 Account in ' Arch, de med. nav.,' 1865, Oct., p. 284. 

" Account in 'Lancet,' 1875, June, p. 865, July, p. S3} Squire, in 'Med. Times 
and Gaz., 1877, March, p. 323. 
" Vinson, ' Topogr. med. de la Nouvelle Caledouie.' 


§ 45. Epidemic Recurrence. 

Like smallpox, measles has appeared repeatedly in far- 
reaching epidemics, sometimes in almost pandemic diffusion 
over the globe, to vanish again from the arena of national 
sickness after two or three years' stay. Of outbreaks of that 
kind during the present century — for earlier times no opinion 
can be formed owing to the defects of the epidemiological 
record — the most notable were: those of 1 796-1801 in 
France, Germany, and England, 1801 in North America, 
1807-8 in Great Britain, 1823-4 in Germany, 1826-28 in 
the Netherlands and Germany, 1834-36 over the greater 
part of Northern and Central Europe, 1842-3 in Switzerland, 
France, the Netherlands, Germany, and Russia, 1846-7 in 
Northern and Western Europe and in North America, and 
1860-63 in Germany. 

But an epidemic of measles may develop here and there 
independently of such outbreaks as those, and not unfre- 
quently at quite isolated spots. As in the case of smallpox, 
many observers think that they have discovered a iJeriodicity 
in the recurrence of these local epidemics. The intervals have 
been variously calculated at different places : for example, 
at two to three years, according to the data of Ranke^ 
(Munich) and Mann (Halle) f at three to four years, accord- 
ing to Spiess^ (Frankfurt-on-the-Main), Geissler* (Meran), 
Kostlin^ (Stuttgart), Rigden,^ (Canterbury), and Guys 
(Aleppo) ; at four to five years, by Macher (Gratz) ; and at 
five to six years, by Thuessink (Groningen), Bartscher'' 
(Osnabriick), and Blower^ (Bedford). In order to arrive at 
the import of these figures, we have in the first place to 
observe that at many other places no such regular recurrence 
in the epidemics of measles has been found. Thus the disease 

' ' Jahrb. fiir Kinderhlkd.,' 1869, ii, p. 34. 

^ ' De morbillis epid. Halis obs.,' Hal., 1848. 

3 ' Jahresbericht (Med.) dcr Stadt Frankfurt a. M./ 1867. 

* ' Vii'rteljabrschr. fiir Oeffentl. Gesundhcitspfloge/ 1871,11!, p. 34, 

* 'Arcliiv des Vereins fiir wissensch. Heilkd.,' 1865, ii, p. 328. 
« 'Brit. Med. Journ.,' 1869, April, p. 348. 

7 'Journ. fiir Kinderkr.,' 1866, xlvii, p. 28. 
5 'Assoc. Med. Jourii.,' 1857, Nov., p. 924. 



was prevalent at ErlaugonMn the years 1819-25-31-39-47-52- 
56 ; at Christiania" in 1824-28-33-39-47-56-61-67 ; atBasel* in 
1824.28 -31 -32.34-35-36.38.44-49-54-57-60-61-62-64-67-69- 
70-73; while in Prague'* the intervals, in the period from 1823 
to 1848, amounted to about four years, from the latter date 
to i860, on the average, to two years, while since i860 the 
disease has been more or less widely epidemic every year. 
Goldschmidt^ states that in Oldenburg no such epidemic 
periodicity has ever been observed ; in Cape Town, according 
to Scherzer, the disease was three times epidemic in the first 
sixty years of the century, viz. in 1807, 1839, and 1852 ; in 
Martinique, according to Rufz, it was epidemic at intervals 
of ten years, in 1831,-41 and -51 ; in the United States of 
America, according to Chapman, there has been no evidence 
of regularity in tho recurrence of measles, and the statistical 
information before me from Boston, New York, Philadelphia, 
and Baltimore plainly confirms that statement. The recur- 
rence of the epidemic of measles at one particular place is 
connected neither with an unknown something (the mys- 
tical number of the Pythagoreans), nor with *' general con- 
stitutional vicissitudes," as Kostlin thinks ; but it depends 
solely on two factors, the time of importation of the morbid 
poison, and the number of persons susceptible of it. The 
same law, accordingly, applies here as in smallpox epidemics. 

§ 46. iNb'LUENCE OF SeASON. 

A glance at tho area of distribution of measles, extending 
as it does over almost the whole habitable globe, shows that 
the occurrence of the disease is quite independent of climatic 
influences. The disease reaches as far as the morbid poison 
has reached ; and if some districts or tracts of country have 
been hitherto exempted from measles altogether or been less 
frequently the seat of epidemics, the reason of that is to be 

' Kiittlinger, in 'Ba^^r. arztl. Intelligenzbl.,' i860, p. 30. 
^ Reports in Eyr, and Lund in ' FordhL i det Norske med. Selskab i 1868/ 
Christ., 1869, p. 10. 

3 Hagenbacli, in ' Jahrb. fur Kinderhlkd.,' 1875, ix, p. 56. 

■• Topper in ' Allgem. Zeitschr. fur EpidemioL/ 1876, ii, p. 275. 

* 'Hiiser's Archiv fur Med.,' 1845, ^ii, p. 303. 



sought, not iu the geographical position or in the conditions 
of climate dependent thereon, but solely in the fact that in 
the one case no importation of the disease has taken place 
hitherto, and in the other case that the importations have 
been infrequent owing to the commercial intercourse being 
small in amount and mainly by sea. 

However independent of climate, then, measles may be, 
whether in its geographical distribution or, as wo shall see 
later, in the form and character of the disease ; still, wherever 
it has occurred, the influence of certain Muds of weather, 
depending on the seasons, has been observed to have a marked 
effect upon the frequency of its outbreak and the extent 
of its prevalence. This influence is one and the same in all 
latitudes ; it is everywhere the cold season in which the 
epidemics of measles most commonly begin, and in which 
they are apt to spread farthest. 

There is an almost complete unanimity on this point among 
observers at the most diverse points of the globe. In India, 
according to McGregor, Morehead, and others, the season 
for measles falls in the months from February to April, or 
in the cold season ; the same is true for Brazil, according to 
Sigaud and Rendu ; in Persia and Egypt, as Polack and 
Pruncr inform us, the disease is mostly prevalent in spring 
and autumn ; Rigler makes the same statement for Turkey ; 
at the Cape almost all the epidemics have been obsei'ved in 
the autumn from April to June (Scherzer) ; in North 
America, the sickness begins mostly towards the end of 
winter and lasts through the spring (Drake) ; and that is 
also the statement made for Switzerland by Hoffmeister,^ for 
Prague by Popper, and for Roumania by Leconte. Of 
30,836 fatal cases of measles in England and Wales in the 
years 1838- 1840 and 1849- 1853, there occurred 8106 in 
the months from January to March, 8907 from April to 
June, 6610 from July to September, and 7213 from October 
to December. The following is a table of 530 epidemics of 
measles in temperate latitudes (Europe and North America), 
the duration of which is accurately given : 

1 < 

Schwciz. Zcitscbr. fiir Med.,' 1849, P- 47 '• 



In Autumn 

In Autumn and Winter 

From Winter to Spring 

In Winter 

In Winter and Spring 

From Winter to Summer 

In Spring 

In Spring and Summer 

From Spring to Autumn 

In Summer 

In Summer and Autumn 

From Summer to Winter 





26 I 


Total in tlie colder months 

Total in the warmer months 
— 191. 

In 213 of tlio same epidemics, of which there is mention 
of their coming to a height, that point was reached forty- 
eight times in autumn, fifty-nine times in winter, seventy-six 
times in spring, and thirty times in summer. 

While there can be no doubt, then, that the season of the 
year, or, in fact, the kind of weather associated with the 
colder months, exerts a certain influence on the rise and 
spread of measles epidemics, the question of how this influence 
is exerted still remains unsolved. That this prevalence of 
the disease in the colder seasons is not in consequence of a 
change in the habits of living associated therewith, — the 
crowding together in close rooms, and the facilities thereby 
afforded for communicating the disease, — may be inferred 
from the fact that the same degree of dependence on the 
season of the year obtains as much in the tropics as in high 
latitudes, — in India, in Southern China, and in Brazil, 
countries where crowding in close rooms can hardly be taken 
into serious account as a factor in the etiology. 

§ 47. Mildness or Severity op Type. 

Just as little does the conformation or character of the 
epidemics of measles appear to depend upon climatic or 
seasonal conditions, or on the weather. There are, generally 
speaking, no real differences to be made out in the course 
which measles runs at the various points of its large area of 
distribution ; everywhere the mucous membrane of the respi- 
ratory organs is, next to the skin, the chief focus of the 
disease as localised, and even the (rarer) implication of the 
intestinal mucous membrane does not appear to be, ceteris 


parihus, more frequent or more severe in the tropical^ or 
subtropical, zones than in liiglier latitudes. 

The character of the disease is in the great majority of 
cases as mild, and its course as favorable, in tropical or sub-- 
tropical as in temperate climates. On this point there is 
much agreement in the accounts of Morehead, McGregor, 
Twining, Huillet,^ and others for India, of Heymann and 
Waitz for the East Indies, of Dudgeon for China, Polak for 
Persia, Gauthier for Senegambia, Schwarz" for Rio Janeiro, 
Boyd for Chili, and of others for still other countries. 
Accordingly, when we hear from some observers, such as 
Curran for the southern slopes of the Himalaya, Hamilton 
for Honduras, and Davidson for Madagascar, of a peculiarly 
malignant form of the disease, wo must look for an explana- 
tion of that fact, not by any means in the circumstances of 
the climate, but chiefly in certain habits of living to be^ 
afterwards mentioned, which make themselves felt most 
wherever the principles of hygiene and of rational therapeutics 
have been most grievously sinned against. 

Statistics give no support to the notion that the season of 
the year or the kind of weather has in itself any real eifect 
on the character of the epidemic. Among the accounts 
before me of epidemics of measles in temperate latitudes, I 
find 285, in which somewhat definite statements are made 
regarding the mildness or severity of type. They divide 
themselves as follows : 

In Autumn. 

In Winter. 

In Spring. 

In Summer. 

Of a mild type . . 55 
Of a severe type . . 10 
Proportion of severe to mild i to 5'5 


. 1 to 4-9 



. I to 57 


• 1 to 5-3 

The proportion of mild to malignant epidemics is, there- 
fore, tolerably uniform in all seasons ; and this result is fully 
borne out by the numerous individual observations made for- 
those epidemics which extend over longer periods. The- 
severity of epidemics of measles depends in great part on 
the intensity of the affection in the organs of respiration and 
digestion ; and thus, from the fact that the epidemics irt 
summer and winter are more often unfavorable in character 

^ 'Arch, dc mod. iiav.,' 1868, Jan., p. 24. 
* 'Zcitsclir. derWien. Acrzte,' 1858, p. 579. 


'tliau those of spring and autumn, the conclusion might be 
drawn a iniori, that the severity of the summer epidemics 
depends for the most pai-t upon the more considerable impli- 
cation of the intestine (catarrh and dysentery), and of the 
winter epidemics upon the intensity of the process in the 
respiratory organs (croup, capillary bronchitis, broncho- 
pneumonia). But this assumption is not warranted by the 

Thus Poinmer' says, of the 1S37 epidemic at Heilbronn, that, while iu 
the summer time it had a severe character from being complicated 
^vith croup, its course in the autumn, and on to its termination in 
December, was altogether more favorable. In the epidemic from 
January to autumn, 1837, at Ahrvveiler (Gov. Depart., Coblenz) the type 
of the disease was very favorable in the spring months, and it was not 
until the setting in of the dry and hot weather of summer that it 
became dangerous from ci'oup complications.* The epidemic of measles 
at Brussels in the spring and summer of 1837 owed its character for 
malignancy to the severe pneumonic attacks in the summer months,^ 
and the circumstances were repeated the same year at Paris,* without 
the influence of the weather in either case being chargeable as the 
cause of the pneumonia. In the epidemic that prevailed at Dublin in 
1844, ill inild summer weather, the somewhat high rate of mortality 
among the sick was mostly due to croup.*^ On the other hand, there 
have been many epidemics of measles observed within the temperate 
zone, which took on a malignant character in consequence of a severe 
intestinal affection ; but in none of them did the season of the year or 
the kind of weather serve to explain this modification of the morbid 
process ; as examples, may be mentioned the epidemic in the autumn 
of 182 1 at Salem (Mass.),' a similar epidemic in 1832 at Berlin,^ and in 
1837 at Hamburg,^ and, in winter, 1837-38, at many parts of Wiir- 
.temberg,9 1846-47 at Hamburg,'" 1848 at Jackson (Miss.),'' and 1853 ^^ 
the department of the Haut-Saone. 

There is, however, no doubt that states of the weather, iu 
-SO far as they affect definite groups of organs, cause these to 

^ 'Salzb. med.-chir. Ztg.,' 1828, No. 28, ii, p. 30. 

' ' Sanitatsber dcs Rheiu. Med.-Colleg. fiir das Jabr 1837,' p. 29. 

^ Daumerle in ' Bullet, med. Beige,' 1839, "j P* 33' 

* Account in * Gaz. m^d. de Paris/ 1837, No. 25. 

* Lees in 'Dubl. Quart. Journ.,' 1844, Sept. 

^ Pierson iu 'New Engl. Journ. of Med.,' 1822, xl, p. 122. 

^ Lieber iu 'Casper's Wocbenschr. f. Heilkde.,' 1833, i, p. 264. 

* Warburg in • Hamb. Zeitschr. fiir Med.,' ix, p. 10. 

^ Account in ' Wiirttemb. med. Corrcspondenzblatt,' 1841, xi, 187 — 189. 
■"> Stablmanu in ' Hamb. Zeitschr. fiir Med.,' xxxvi, p. 18. 
-" Ferrar iu 'Southern Med. lleports,' 1850, i, p. 354. 


become the locus miiwris resisteniia, and therefore the seat 
of the diseased action ; and, as a matter of fact_, the process 
of measles in tropical regions appears from the statements 
of Morehead (India), Ferrini (Tunis), Daniell (West Coast of 
Africa), and Sigaud (Brazil), to be more often accompanied 
by severe affection of the intestine than in temperate lati- 
tudes. But in those regions, also, this configuration of the 
disease obtains at times when weather influences cannot well 
be regarded as the cause of it ; as, for example, in the 
severe epidemics of measles in Java in the winter (December 
— January) of 1849 and 1850,^ and at Bombay in the months 
of March and April, 1857." 

There is not the very smallest ground for the belief that 
local conditions of the soil exert an influence on the rate of 
diffusion or on the type of measles. When Fuchs^ says that 
" in the north, and in elevated districts, the inflammatory form 
occurs, while in the south and in flat stretches of coast it is 
more usually the asthenic and putrid form," ho omits at the 
same time to give his proof for this statement ; and when he 
adds : " England, Holland, and many parts of the French 
coast are noted for having been long the scene of the most 
malignant epidemics of the disease, and the frequent occur- 
rence of putrid measles in marshy lands leads one to think 
that miasmata may have helped to generate this worst of all 
varieties " — I can nowhere find any facts to justify the asser- 
tion. Thuessink, to whom we owe an excellent work upon 
the occurrence of measles in the Netherlands in recent times, 
does not say one word about any malignant character of the 
disease, such as has been attributed to that country ; and 
the epidemic of measles in 1847-49, which was diffused over 
the whole country, ran a course that was almost uniformly 
favorable. The little influence that this factor has on the 
character of the disease is further shown in the fact that it 
is precisely in the great marshy districts of many tropical 
regions that measles has, generally speaking, a very mild 

' Brockmeyer, in 'Arch, cle med. nav.,' 1868, Dec, p. 415. 
^ Carter, in ' Bombay Med. Transact.,' 1859, n.s., iv, p. 253. 
^ ' Die Krankhaften Veraudcruugen der llaut,' Abt. iii, p. 36 1. 


§ 48. Severity op Type due to Neglect op the Sick. 

In considering the reason why some epidemics of measles 
should have had a malignant type, great stress, in my 
opinion, should be laid on onistalies in dieting and in thera- 
;peutic treatment. Without doubt it is here that wo have the 
explanation of the fact that the disease in past centuries had 
a much more unfavorable typo than in recent times. In form- 
ing an opinion, however, on this point, we should bear in 
mind that many epidemics of measles adduced in evidence 
from the eighteenth century were, in fact, outbreaks of 
scarlet fever. But there still remain a considerable number 
of true measles-epidemics of that period, whose malignant 
character was due in the last resort, as the chroniclers them- 
selves admit, to the way in which the sick were treated. 
Even for many of the epidemics of the last thirty or forty 
years, remarkable for their very considerable mortality, it 
could be shown that reactionary dietetic and therapeutic 
practices gave the epidemic its malignant character. The 
importance of that factor in the causation comes out in the 
clearest way in those epidemics of measles which, springing 
up among uncivilised peoples, have run a disastrous course in 
the absence of all rational treatment of the sick. 

L Classical examples of this are furnislied by the epidemic of 1749 
among the natives on the banks of the Amazon, where the number of 
those that died of the sickness was reckoned at 30,000, whole tribes 
having been cut off ;^ also in Astoxiii in 1829, where nearly one half of the 
natives fell victims to the disease namong the Indians of Hudson's Bay 
Territory in 1846 ;^ among the Hottentots at the Cape in 1852 ;* among 
the natives of Tasmania^ in 1854 and 1861 ; and in Mauritius and 
the Fiji Islands in 1874. Concex-ning the two last mentioned epi- 
demics, both of them disastrous, it is stated in the report:^ — "The 
great mortality has been in large measure due to the fact that the sick 
were exposed to the most unfavorable conditions. Unprotected from 
exposure, unattended and untreated, chiefly in consequence of their 
own unhappy prejudices, every complication of the disease must have 
been invited and rendered intense ; in accordance with this view, we 
find that those classes of the native population over whom adequate 
supervision could be exercised have suffered slightly." SmeUie men- 
tions facts of the same kind in the destructive epidemic of 1846 among 

' Sigaud, p. III. * Moses. ^ Smellic. * Scherzer. ^ HalJ. 

® ' Lancet,' 1875, June, p. 86.1;. 


the natives of Hudson's Bay Territory ; of all those who were received 
^into Fort York, and who there received medical treatment, not one died. 
[_ In the account given by Squire' of the frighful epidemic of measles in the 
Fiji Islands, which was known to have been introduced from Sydney by 
the retinue of King Kakobau, and which carried off 20,000 of the natives, 
or one fourth to one fifth of the whole population of the Fiji group, we 
find the following : 

" The favorable progress of the early native cases negatives the idea 
of any special proclivity. Dr. Cruikshank, who treated 143 of the native 
constables, reports nine deaths, most of these resulting from evasion of 
needful precautions. Later in the epidemic, when it is said to be like 
plague, and that the people, seized with fear, had abandoned their sick, 
only one death occurred among a number of cases treated in separate 
rooms with fair attention. . . , The people chose swampy sites for 
their dwellings, and whether they kept close shut up in huts without 
ventilation, or rushed into the streams and remained in the water during 
the height of the illness, the consequences were equally fatal. The 
excessive mortality resulted from terror at the mysterious seizure, and 
[from] the want of the commonest aids during illness. . . Thousands 
were carried off by want of nourishment and care, as well as by 
dysentery and congestion of the lungs. . . We need invoke no special 
susceptibility of race or peculiarity of constitution to explain the great 

But it is not necessary that we sLould seek in so distant 
regions and among uncivilised peoples for proofs of the 
disastrous influence of unfavorable hygienic conditions upon 
the type of epidemics of measles on a large scale. r'ln the 
epidemic which prevailed in 1866 among the Confederate 
troops during the American Civil War, there were 1900 
deaths out of 38,000 cases of sickness. 1 In the official report/ 
it is stated that " the disease resembled ordinary measles in 
adults, except when aggravated by the effects of crowd, 
poisoning, or other depressing influences -, " in two large 
hospitals, the mortality amounted to 20 per cent, of the 
sick. (, In Paris during the siege (January, 1871), out of 
215 of the Garde Mobile who took measles, 86, or 40 per 
cent., died ;Jand the mortality reached very nearly the same 
figure among the French troops who returned to Paris after 
the Italian war, 40 out of 125 cases dying in one hospital, 
(whose sanitary condition was bad) with severe intestinal 
symptoms.^ Speaking of the disastrous epidemic of measles 

' 'Med. Times and Gaz.,' 1877, March, p. 323. 

' 'Med. History of the Rehcllion,' Phihid., 1865, p. 127. 

' Lavcran, in ' Gaz. hebdom. de nied.,' 1861, No. 2. 


ill the Natioual Army of Paraguay, Mastcrmaii^ says : '' At 
the bcgiuuing of the Brazilio-Paraguayan war, an cpidomic 
of measles swept off nearly a fifth of the National Army in 
three months, not from the severity of the disease, for I 
treated about fifty cases in private practice without losing 
one, but from want of shelter and proper food/' 

I will not say that these considerations enable us to under- 
stand completely why some epidemics of measles are of a 
severe type ; there may be still other factors, acting on the 
physiological disposition of the people in a given locality, or 
there may be even a concentration of the morbid poison, 
determining the unfavorable type of the epidemic. But 
the favourite phrase '' constitutio cpidemica " does not help 
us at all in the elucidation of the question. 

§ 49. The Specific Poison op Measles. 

It will hardly bo questioned nowadays that a, specific poison 
underlies the disease of measles, that this poison repro- 
duces itself within the diseased organism, and that the spread 
of the disease from person to person and from place to place 
takes place solely by the conveyance of the poison. As to 
the nature of the poison, which, as it is capable of reproduc- 
tion, must at all events be taken to be an organic body or to 
issue from a special organic body, we have investigations by 
Salisbury," Klebs,^ and others ; but the result of those 
inquiries has not as yet been confirmed. We are also without 
any certain information, up to the present, as to organ or 
organs of the sick person by which the poison is elimi- 
nated, whether by the skin only or by the mucous membranes 
as well. So much may be safely concluded : that the virus 
passes from the sick into the atmosphere around, which 
thereupon becomes a carrier of the infective substance within 
a certain short range, not ascertainable more accurately ; or 
that it is deposited from the air upon articles (linen, clothes, 
&c.) which have been used by the patient or have been in 

' L. c, p. 384. 

' 'Amer. Journ. of Med. Sc.,' 1862, July 17, Oct., p. 387. 
^ ' Verhandl. dcr Wiirzb. Phys.-mcd. Gesellsch.,' 1874, n. s. vi, Sitzungsbericlit, 


his immccliato proximity ; and that it may bo brought, cling- 
ing to these, into other rooms, there to give rise to new foci 
of infection. 

All that we may infer from observed facts as to the 
tenacity of life of the virus of measles, has been already 
stated in the beginning of this chapter. The area of the dis- 
ease extends, as wo have seen, to wherever the morbid poison 
has been imported, and the disease lasts as long as the poison 
can find a soil in which to multiply — in the bodies of those 
who aro susceptible. This susceptibility to the virus of 
measles is proved by the geographical distribution of the 
disease, to bo uniformly shared by the whole of mankind, of 
whatever races or nationalities. And if, among the coloured 
peoples, measles puts on its severest forms and loads to dis- 
astrous results exceptionally often, the reason of that does not 
lie in their physiological peculiarities, but mainly, as we havo 
seen, in the unfavorable hygienic conditions amidst which 
they live. 


§ 50. Historical Notices Defective. 

The earliest information about scarlet fever, to which any- 
historical certainty appertains, goes hand in hand, as we have 
seen, with the information about measles. Both morbid 
processes were discussed in common, under various designa- 
tions, by the mediaeval physicians as well as by those of the 
earlier centuries of the modern period ; and as late as the 
17th century, after the special features of the scarlatinal 
process had come to be recognised, many physicians clung 
to the opinion that it was only a modification of measles. 
It was not until the middle of the eighteenth century that 
a perfectly clear understanding on this point was arrived 
at ; but there was introduced into the doctrine of scarlet 
fever at the same time a new error, which makes itself 
heard even at the present day. One-sided emphasis placed 
on the inflammatory process in the throat, which so often 
occurs in scarlatina, led to its being confused with angina 
maligna (diphtheritis of the throat), and the papular or 
vesicular efilorescences that occur not unfrequently in cases 
where the cutaneous exanthem is severe, led to its being 
confounded with miliary fever. Those errors are reflected 
in the historical inquiries of Most,^ Fuchs,^ Hecker,^ and 
others ; I shall postpone the discussion and correction of 
them until I come to treat of the history of malignant 

The origin and native habitat of scarlatina are questions 
that do not admit of an answer ; we are equally unable to 

1 ' Versuch einer kritischen Bearbcitung der Gescliiclite des Scharlachfiebcrs, 
&c.,' 2 vols., Leipzig, 1826. 

' ' Historische Untersucliuugen iiber Angina raaligua,' Wiirzb., 1828. 
' 'Geschicbte der ceueren Heilkunde,' Berlin, 1839, 200 — 274. 


■decide as to the time wlieu the disease first attained its 
general prevalence ou tlie Continent of Europe. It was at 
any rate long before the period from which we derive the 
earliest medical accounts of scarlet fever; and the state- 
ments that it first appeared in England and Scotland iu 
1661/ at Berlin in 1716/ at Florence in 1717,^ and in 
Denmark in 1 740/ arc most probably to be accounted for by 
the circumstance that the disease, now that it had been recog- 
nised by its special features, had then attracted the particular 
attention of the profession and the public. When and where 
scarlet fever first appeared on Asiatic n,n^ African soi^ cannot 
be made out even approximately. On the continent of North 
America it was probably in 1 735, and in New England, that 
scarlatina first obtained a footing ; the first occurrence of 
the disease in South America falls in the years from 1829 to 
1 83 1. On the Australian continent and iu PoJijncsia it was 
first seen in 1847-48 ; of which more iu the sequel. 

The oldest notice relating probably to an epidemic of 
scarlatina dates from Sicily, 1543 -^ next come the well- 
known accounts by Coring'' for Breslau, and by Sennert^ for 
Wittenberg in the year 1627; then the report by Winsler* 
for Brieg, 1642, and that by Fehr^ for Schweinfurt, 1652 ; 
further, the works of Sydenham,^'^ who contributed materially 
to the correct understanding of the disease, and of his 

' Sibbald, ' Scotia Illustrata,' Edin., 1684, p. 55. 

^ Gobi, 'Act. mod. Berolin,' Dec. i, vol. i, p. 30, ii, p. 4. 

3 Calvi, in Roucalli Parolino's ' Europae Mediciiia,' Brix., 1747, p. z^^. This 
author, who refers to Sydenham, and gives a good description of the disease, 
remarks : " Febris prima epidemia triginta circiter abhinc annis Floreutiae 

■• Wernicke, ' Spec febri scarlatina,' Hafn., 1760, p. 23 ; ''constat, 
ilium [morbum] his in terris vix cognitum fuisse, sed primo intra 1740 ad 
1750 hie inclaruisse." 

* Compare Corradi (' Anuali delle epidcm. occorse iu Italia,' ii, p. 287), for a 
reference to the treatise by Paulus Restifa (' Epistol. med. ad Franciscum liissum,' 
&c., Messina, 1589), who gives an account of this epidemic. 

^ In Sennert's ' Epistol.,' Cent, i, ep. 88, 0pp. Lugd., 1676, vi, p. 620. 

' lb., Cent, ii, ep. 20, 1. c, ]>. 644. 

** ' Ephemer. nat. cur.,' Dec. i, Ann. 6 et 7, 1675-76, Obs. 42. 

^ ' Auchora sacra, &c.,' Jena?, 1666, p. 90. 

'" 'Observ. med.,' Sect, iv, cap. ii, Genev., 1736, i, p. 162. It is probable that 
.Sydenham was not the first to use the term " febris scarlatina;" iu the ' Monuui. 
-stor. Moden.' of Lancellotti, i, 208,382, as Corradi points out, there is a reference 
under the year 1527: "Che nella primavcra, meutro puti (putti) assai hauo ii 


countryman Morton -^ and subsequent accounts from France^ 
{1712), from Sweden' (1741), and from tlic Netherlands.* 
Among' the best works on scarlet fever of that period^ are 
those of Storch/ based upon observations — he gives an 
account of more than 190 cases — made at Gotha in the years 
from 1 71 7 to 1740. 

§ 51. Pkesent Geographical Distribution. 

By far the largest area of distribution of scarlet fever is 
met with on European soil. In Germany, France, the 
Netherlands, England,^ and the Scandinavian kingdoms, this 
disease is one of the chief factors in the statistics of sickness 
and mortality. In Russia also, it appears to be somewhat 
widely prevalent.'^ 

That the most northern as well as the most southern 
countries of this part of the globe enjoy no real immunity 
from the sickness is proved, on the one hand by the account 
of Schlcisner^ for Iceland, and, on the other hand, by those 
of Menis^ and Do Eenzi for ITpiicr and Lower Italy ; of 

vnroH, altri muojono da male da scarlatina." It is, however, an open question 
whether " febris scarlatina " is really meant here. 

' ' Pyretologia,' Cap. v, Genev., 1696, p. 28. 

2 In ' Journ. de med.,' 1763, Juno, p. 551. 

•* Rosenstcin, ' Auweisung zur Kenntn. und Kur der Kinderl<r.,' Gott., 1768, 


'' De Ilaen, ' Thes. sist. febr. divis.,' Vindob., 1 760, p. 25 ; ' Ratio med.,' i, p. 96. 

^ 'Pract. und theoret. Tractat. v. Scharlachfieber, &c.,' Gotha, 1742. 

* In England and Wales the annual mortality from scarlet fever, on the 
average of eight years from 1848 to 1855, was one twenty-fifth of the total 
mortality, and there were many years in which it was as much as one twentieth 
(Farr, in ' Annual Report of the General,' 1857, p. 180). 

7 There is a noteworthy remark hy Ucke (' Das Kliina und die Krankhelten 
der Stadt Samara,' Berl., 1863, p. 198), that scarlet fever is so extremely rare in 
Samara that the public has no knowledge whatever of the disease, and that 
there is therefore no colloquial name for it. 

* ' Island undersogt, &c.,' p. 53. The disease was epidemic there in 1797 and 
1827, probably also as early as 1669 and 1776. In 1848 a few cases were 
observed (' Sundhedskoll. Forhandl. for aaret., 1849,' p. 9) ; while Finsen (' Syg- 
domsforholdene i Island,' p. 47) did not see a single case during a ten years' 
residence on the island (1856-66). The Faroe Islands, according to Panum, had 
quite escaped the disease up to 1847 ; ^ ^"^ 'i^t acquainted with any later data 
as to scarlet fever there. 

* ' Saggio di topogr. stat.-med. della provincia di Brescia, &c.,' Bresc, 1837, i, 
p. 154- 


Oppcnlieim^ and Eig-lcr^ for Turlicy ; of Olympios^ for 
Greece, of Moris'* for the island of Sardinia, and of Zulati' 
and Jonncr*' for tlie Ionian Islands and Malta. 

A highly striking contrast to this frequency of scarlet fever 
in EuropCj especially in its Central and Northern parts, is 
presented by its very scanty diffusion hitherto in Africa and 
Asia. It is rare all over the East, and especially so in 
Egypt (says Pruner^), being seen mostly in sporadic cases of 
a mild type, while in the south of Egypt the disease does 
not appear to occur at all.^ There are accounts to the same 
effect, of the amount and character of the disease in Aln/ssinia,^ 
Tunis}^ Sencgamhia^^ the Cape^^ and Madagascar P It is only 
in Algiers that scarlet fever is said to be somewhat common,^'^ 
and to occur, in fact, not unfrequentlyin malignant cpidemics.^^ 
In the Azores it has often been epidemic.^^ Into Madeira it 
was introduced for the first time at the beginning of this 
century ;^^ there was no return of it between the years 1814 
and 1824; and in the medical reports from the island for the 
subsequent period,^^ it is spoken of as a disease occurring 
seldom, and then of a mild type. 

' 'Ueber den Zustand der Heilkunde in der Tiirkei,' Hamburg, 1833, p. 56. 

- Op. clt, ii, p. 23. 

■' • Bayr. med. Correspondenzblatfc,' 1840, p. 178. 

* In De Marmora's ' Voyage en Sardaigne, &c.,' Paris, 1826. ' 

* ' Giorn. di med.,' Venezia, 1764, ii, p. 224. 

^ ' Sketcbes of the Med. Topogr. of tbe Mediterranean, &c.,' Loud., 1830. 
' ' Krankb. des Orients,' p. 1 20. 

^ Hartmann (' Skizze der Nil-liinder,' p. 419) mentions, on hearsay evidence, 
the occasional occurrence of epidemics in the southern countries of the Nile 

'•* Blanc in 'Gaz. hebd. de mod.,' 1874, No. 22, p. 349. 
w Ferrini, p. 1 54. 

" Chassaniol in 'Arch, de motl. uav.,' 1865, May, p. 506; Gauthier, 'Des 
Endemics an Senegal,' Paris, 1865, p. 18. 

'•' Scherzer in ' Zeilschr. der Wiener Aerztc,' 1858, p. 156; Egan, in 'Med. 
Times and Gaz.,' 1873, June, p. 682. 
'* Borchgrcvink in 'Norsk Magaz. for Laegcvidensk,' 1872, p. 247, 
'■' Guyon in 'Gaz. med. de Paris,' 1839, ^^- 4^5 Gaucher in 'Gaz. med. de 
I'Algerie,' 1869, No. 3, p. 34. 
^ Clandot in ' Rcc. de mem. de med. milit.,' 1877, p. 193. 
" Nogucira in ' Jorn. da socied. das scienc. med. de Lisboa,' xxiii. 
'^ In 1806, according to Qourlaj', 'Med. and Phys. Journ.,' 18 11, May, p. 430. 
See also Heinckcn in 'Lend. Med. Reposit.,' 1824, July, p. 14. 
13 Kilmpfer in ' Ilamb. Zeitschr. fiir die ges. Med.,' 1847, x.\.\Iv, p. 166. 


On Ab-iatic soil, the coast of Asia Minor appears to be the 
only region which is frequently visited by scarlatina in its 
severe forms.^ In Syria,^ Mesopotamia^ Persia,* and 
Arabia,'' the disease is seen only in rare sporadic cases, if 
it occur at all ; and that is also the state of matters in the 
Tlast Indies,'' in Further India^ and most probably also in 
British India. As regards the last, some observers, such as 
Chevers^ for Bengal, Rhude^ for Tranquebar, Huillet^'^ for 
Pondicherry, the authors of reports from Madras,^^ Collins^^ 
for the plateau of the Deccan, Morehead^^ for Bombay, and 
Evans^* for Mirzapore, declare that neither has any case of 
scarlet fever come under their own notice nor has any such 
case been proved to have occurred in India at all ; while 
others, particularly Hogg^^ and a few practitioners in Lower 
Bengal, ^'' remark that the disease has often been im- 
ported into India, but has never become epidemic there, 
having been always limited to a few mild cases among 
European or Eurasian children. There are unquestionably 
mistakes in diagnosis underlying these statements as to the 
isolated occurrence of scarlatina in India, especially the mis- 
taking of dengue for it ; and, considering this, Milroy^^ comes 
to the conclusion that the disease is clearly proved to have 

' Pruuer, 1. c. 

* Pruner; Tobler ('Zur med. Topogr. v. Jerusalem,' Berl., 1855, p. 46). 
Robertson ('Edin. Med. and Surg. Jouru.,' 1843, July, p. 57) makes no mention 
of scarlet fever beside smallpox and measles. 

3 Ffloyd, 'Lancet,' 1841. 

* Polak, in 'Wiener med. Wochenscb.,' 1855, No. 17. 
^ Palgrave, in ' Union med.,' 1866, No. 20, p. 308. 

^ Heymann ('Krankb. in den Tropenliiudern.,' Wiirzb., 1855, p. 224), during 
a long residence in Java, saw only a few sporadic cases. 

7 Dawson ('Philad. Med. Examiner,' 1852, May) says tbat be bad beard of 
scarlet fever occurring in Burmab among tlie cbildren of tbe Englisb mission- 
aries ; Breton (1. c.) mentions tbat tbe disease is very I'are in Anam. 
^ ' Med. Times and Gaz.,' 1879, Jan., p. 4. 
^ 'Bibl. for Laeger,' 1831, April, p. 263. 
'•^ ' Arcb. de med. nav.,' 1868, Jan., p. 25. 

" In ' Report of tbe Sanitary Commissioners for Madras,' 1869. 
12 'Ind. Annals of Med. Sc.,' i860, Nov., p. 5. 
'^ * Researcbes on Diseases in India,' i, p. 360. 
'* ' Edin. Med. Journ.,' 1855, Aug. 
'5 ' Med. Times and Gaz.,' 1876, Sept., p. 253. 
's ' Indian Med. Gaz.,' 1871, Oct., p. 2. 
'7 'Transact, of tbe Epidemiol. Soc.,' 1865, ii, p. 156. 


existed at one point only, viz. Colombo in Ceylon, and there 
merely to a sliglit extent and in a mild form. In the 
Southern and South-Eastci"n coast towns of China, it occurs 
very rarely, if at all -^ I am unable to decide what ground 
there is for the assertion of Moracho~ that the disease has 
been often epidemic in Pckin. In Jajinn, it is said by 
Wernich^ to be quite unknown. 

Scarlatina reached Austndia and Tohjncsia, first in the 
beginning of 1848 ; the disease broke out almost simulta- 
neously in Tahiti,^ New Zealand/ and Tasmania,^ but every- 
where to a limited extent and in a very mild form. In 1853 
it appeared afresh in Tasmania, and in 1854 in New Zcaland,'^ 
reaching the Australian continent simultaneously. More 
special details of the scarlet fever in that part of the world 
have not come under my notice ; there is a solitary reference 
to a malignant epidemic in Melbourne in the year 1876.^ 
With the exception of Tahiti, the islands of Polynesia appear 
to have escaped the disease hitherto. 

The first appearance of scarlet fever on the soil of North Ame- 
rica dates from 1735 ; according to Douglas^ and Colden,^° the 
disease broke out first in Kingston, Mass., it followed quickly 
in Boston and other places near, and a little later in New 
Hampshire, overran the whole of the New England States in 
the course of the next few years, came next to New York 
and to Philadelphia in 1746, as Morris^^ asserts on the autho- 
rity of a manuscript note by Kearsley, and travelled thence, 

' ' Armaiul, in ' Gaz. mod de Paris,' 1861, No. 17, p. 201 ; IJocliefort, in 'Arch, 
de Died, nav,,' April, p. 241 J Dudgeon, in 'Glasgow Med. Jouru.,' 1877, Julj, 
p. 328. 

- ' Annal. d'liyg./ 187c, Jan., p. 55. 

5 'Deutsche med. Woehensclir.,' 1871, No. 9, p. 101. 

'' Account in 'Arch, de mod. nav.,' 1865, Oct., p. 283. 

^ Thomson, in 'Brit, and For. Med.-Chir. Rev.,' 1855, April. 

* Hall, in ' Transact, of the Epidemiol. Soc.,' 1865, ii, p. 72. 

" Tuke, in ' Edin. Med. Journ.,' 1864, Feh., p. 721. 

' ' Brit. Med. Journ.,' 1876, May, p. 609. 

^ ' The Practical History of a New Epidemical Eruptive IMiliary Fever,'" 
Boston, 1736. Reprinted in the 'New England Journ. of Med.,' 1825, Jan., 
p. I. Fuchs, Hccker, Haser, and others who mention this paper in writing of 
angina maligna (diphtheria), can hardly have read it in the original, otherwise^ 
they would not have taken the disease to be anything but typical scarlet i'evcr. 
"' ' Lond. Med. Obscrv. and Inquiries,' 1754, i, ji. 211. 
" 'Lectures on Scarlet Fever,' Philad., 1S51. 


as it appears, along the Atlantic coast to South Carolina, 
where it is referred to by Chalmers,^ towards the cud of the 
eighteeuth ccntuiy, as being certainly of rare occurrence. 
In 1784 scarlet fever reappeared in the Northern States, and 
in 1791—93 it penetrated for the first time into the interior 
of the continent, particularly into Kentucky and Ohio.^ 
During the present century it has become general, from 
Canada (where it was especially prevalent in 1843, fi'om 
Toronto onwards, over a wide area)'^ to the Gulf Coast States. 
In the Southern States, whence we have epidemiological data 
for the year 1821 from Arkansas*, 1832 from Augusta, Ga.,^ 
1833 and 1843 from Alabama," 1847 from New Orleans,^ and 
1854 from Raleigh, N. Car.,*^ the occurrence of scarlet fever, 
according to the unanimous opinion of observers, is much 
rarer than in the Northern. It appears from Sozinsky's 
interesting statistical notice^ of the distribution and amount 
of the disease, based on the results of the U. S. census of 
June, 1870, that, while the yearly mortality was from 30 to 
160 per 100,000 inhabitants in the New England States, New 
York, New Jersey, Pennsylvania, Maryland, Ohio, Virginia, 
Indiana, Illinosis, Michigan, Wisconsin, and Iowa, it fell to 
between i 'o and 9*4 in Tennessee, North and South Carolina, 
Georgia, Alabama, Mississippi, Louisiana, Florida, Arkansas, 
and Texas. Greenland has escaped scarlet fever hitherto,^^ 
with the exception of a single case in 1848, a child of the 
district physician Rudolph. It has shown itself now and 
then in Newfoundland ;^^ but there is no information about it 
from Nova Scotia, New Brunswick, and Hudson^s Bay Ter- 

^ 'Account of tlie Weiither aud Diseases of S. Carolina,' Lend., 1776, vol. il 
\Germau. transl., 1796, ii, p. 209). 

* Drake, 1. c, ii, p. 599. 

2 Stratton, iu ' Ediu. Med. and Surg. Journ.,' 1849, April, p. 269. 

^ Huutt, in ' Amer. Med. Recorder,' 1822, v, p. 277. 

5 Robertson, in 'Amer. Journ. of Med. Sc.,' 1834, Feb. 

^ Basset, in 'South. Med. Reports,' 1850, 5, p. 266 ; Bates, lb., p. 313. 

' Rhodes, ib., p. 239. 

^ McKee, in ' Transact, of the Carol. State Med. Assoc.,' 1856. 

•■> ' Philad. Med. and Surg. Reporter,' 1880, Jan., p. 68. 

1" Account in ' SnndhedscoU. Forhandl. for aaret 1848,' p. 7 ; Lange, ' Bemaer- 
lininger om Grunlands Sygdomsforhold.' Kjobenh., 1864, p. 37. 

^^ Gras, ' Quelques mots sur Miquelon,' Montp., 1867, p. 30; Anderson, in 
' DobcU's Reports,' 1870, i, p. 365. 



ritory. On the Pacific coast of Nortli America it was seen 
first in 1851 in California;^ at the outset it occurred only in 
isolated cases and in a very mild form, but subsequently there 
have been epidemics of malignant scarlatina. Its epidemic 
occurrence in Mexico is mentioned by Strieker" and by 
Robredo f on the other hand, Heinemann states that not a 
single case of scarlet fever came under his notice during a 
six years' residence at Vera Cruz.* There are only scattered 
notices of the disease from Central America ; Hamilton^ states 
that it is rare in Honduras, bat of a malignant type ; 
Schwalbe** mentions a severe epidemic in Costa llica in 1856. 

I have had no means of finding out wlien scarlet fever 
first reached the West Indies. It is remarkable tliat the 
medical accounts from these colonies in the last century are 
quite silent about the disease ; the earliest mention of it is by 
Savaresy/ and concerns a very mild epidemic in March, 1 802, 
in Martinique ; Rufz saw the disease there also in 1835/ but 
it had not recurred from that time down to 1856. Forstrom^ 
says that it is not uncommon in Guadeloupe, but that St. 
Bartholomew had quite escaped it up to that time (1812) ; it 
first became epidemic in the latter, as Cock states,^° in 1829- 
30. These few notices, and an account by Pop^^ of a severe 
epidemic in Cura9ao, are all that I have been able to collect 
about the disease in those regions. In New Providence 
{Bahamas) , an imported case from America was observed in 
1845 ; Duncome^" communicates this fact, with the remark 
that nothing was known of the disease having occurred on 
the islands during the previous forty years. 

It was about 1 830 that scarlet fever began to be generally 

1 Praslow, 1. c, p. 55 ; Gibbons, ' Annual Address delivered before the San 
Francisco State Med. Soc.,' 1857, p. 'o- 

- ' Hamb. Zeitschr. f. Med./ 1847, ^ol. 34, p. 529. 

2 ' Periodico de la Acad, de med. de Mi'jico,' 1838, Sept. 
^ * Vircliow's Archiv,' 1873, vol. 58, p. 161. 

' 'Dublin Quart. Journ. of Med. Sc./ i863,;Aug. 
•"' 'Archiv fiir klin. Med.,' 1875, xv, p. 3. 
' ' De la fi^vre jaune,' Naples, 1809, p. 23. 
'' ' med. nav.,' 1869, Aug., p. 136. 

3 ' Svenske Liik. Siillsk. Handl.,' 1812, iv, p. 231. 
1" 'Edin. Med. and Surg. Journ.,' 1832, Jan., p. 28. 
" 'Nederl. Tijdschr. voor Genecsk.' 1859, iii, p.'2i2 
'- ' Lancet,' 1846, March. 


diffused over SontJi America. According to Brunei,^ it was 
once prevalent before in 1796 in tlie River riafe States, and 
it broke out anew in 1831 (as Sigaud" also mentions) in 
Buenos Ayres, whence it spread to Monte Video, and in 
1832 reached the southern and central provinces of Brazil 
(Rio Grande, Santa Catarina, Sao Paulo, Miuas) and 
ultimately Kio Janeiro. Since that time, the Argentine 
Republic and Brazil have been visited frequently by severe 
epidemics.^ In Chili also, its first appearance"* corresponds 
to the time of this general diffusion of the disease on the 
eastern side of South America; and it has been often 
observed subsequently in that country in epidemics that have 
been not nnfrequently of a malignant type. There are 
accounts to the same effect, by Tschudi^ and by Smith," of 
its prevalence in Peru. 

§ 52. Peculiarities of Scarlatinal EriDEMics as compared 


A glance at the map of its geographical distribution, as 
here sketched in general outlines, shows that the a7'ca of 
diffusion of scarlet fever is much smaller than that of small- 
pox or of measles ; that the continents of Asia and Africa, 
Avhich, as we have seen, are among the chief seats of these 
two diseases and especially of smallpox, have been visited by 
scarlet fever at the utmost to a very small extent, allowing 
even for imperfections in the record. A further comparison 
of these infective diseases with regard to the manner of their 
occurrence, particularly a comparison of measles and scarla- 

^ ' Observ. mcdicalcs, &c.,' pp. 36, 42. 

2 L. c, p. 208. 

3 See Mantegazza, 'Lettere med. sulla America meridionale,' Milano, 1856, i, 
p. 12; Dupont, 'Observ. sur la cote orientale d'Ameriqne,' Montp., 1868, p. 14; 
Rendu, ' Etudes topogr. et mod. sur le Bresil,' Paris, 1848, p. 66. 

'' According to tbe accounts by Piderit (in the ' Deutsche Klin.,' 1855, No. 
16) and Gilliss ('U.S. Naval Astronom. Exped. to the Southern Hemisph.,' 
Washington, 1855, p. 247) scarlet fever was prevalent there first in 1829, or two 
years before its outbreak in Buenos Ayres ; so that there may have been an 
importation from Chili to the east coast. 

^ ' Oest. med. Woehenschrift,' 1840, pp. 470, 697. 

•' 'Ediu. Med. and Surg. Journ.,' 1840, April, p. 335. 


tiua.^ brings out some otlicr interesting points of difference. 
It is especially significant that scarlet fever occurs as an 
epidemic much more rarely than measles, so that, at a given 
place, there may often be ten or twenty years or more between 
two successive epidemics of the former. 

Thus, to give only a few particularly striking examples, 
there was at Upsala in the latter half of last century only 
one epidemic during a period of thirty-three years ;^ in 
Samara, as we have seen, the disease occurs so seldom that 
it is hardly known to the public ; when the great epidemic 
broke out in Sweden in 1856, thero were many places in 
Wcsterbottenslan which had been free from the disease for 
sixteen years ;^ in his account of the epidemic of 1870 at 
Bristol, Davies^ states that many years had passed since the 
disease last showed itself there ; Miquel* emphasises the 
infrequent occurrence of scarlatina in the department of 
Indre-et-Loire, many years often elapsing before an epidemic 
develops, and Meynet^ makes the same statement for Lyons ; 
Tourtual" gives it as a well-established fact that previous to 
the epidemic of 1822-3 at Miiuster, fifty years had elapsed 
without the disease occurring there ; the last epidemic at 
Emden previous to 1839-40, had been in 1825-6, and there 
had been no scarlet fever for many years previous to that ;^ 
at Ulm for the seventeen years from 1838 to 1855 there was 
only one small epidemic;^ before the epidemic of 1862-63 ^^ 
Tuttliugcn, the malady had not been seen for thirty-five 
years f in Erlangen,^^ it had been epidemic three times in 
the forty years from 18 19 to 1858; Uracil was free from the 
epidemic for sixteen years from 1 829 to 1 844^^^ and there was 
a corresponding clear interval at Stuttgart from 1830 to 

' Rosenstein, ' Kiuderkranklieiten,' p. 417. 
" Account in 'Sundheds-CoUcgii Ueiiittelsc' foi' 1856, p. 23. 
^ ' Brit. Med. Journ.,' 1870, Sept., p. 297. 
•* ' Gaz. med. de Paris,' 1834, No. 27, p. 426. 
^ ' Lyon medical,' 1878, No. 49, p. 504. 
" ' Ilufeland's Journ. dur pract. Huilkd.,' 1S26, Doc. .^. 

' Laporte, in ' Ilaunov. Annalen iiir die ges. Heilkd.,' 1.S41, n. s., i, p. 157. 
^ Majer, in ' Wiirttb. med. Correspdzbl.,' 1857, p. 105. 
' Ilcini, ib., 1864, p. 195. 

'" Kiittlinger, in ' Eayr. iirztL Intelligcnzblatt,' 1S60, p. 29. 
1' Rosch, in ' [Bad.] mod. Aunal.,' 1843, ix, p. 561. 


1846;^ when the disease was prevalent in Baden in 1853-54, 
many places wore attacked in which scarlatina had not been 
seen for fourteen years ;' in Washington County, Ohio, there 
had been no epidemic for twenty-three years f Boston from 
181 1 to 1830 was so little visited by scarlet fever that the cases 
of death from it in those twenty years numbered only forty.'' 

It is at the same time worthy of note that, if the disease 
once grow to an epidemic, it continues not unfrequently for 
several years in one degree or another, and often becomes 
diffused over wide stretches of country. Thus in 1825-26 it 
extended over Denmark, England, Germany, and France ; in 
1832-35 again over those countries together with Ireland and 
Russia; in 1846-49 over Germany, Denmark, England, and 
Scotland; in 1821 and 1851 over North America; in 1831-37 
over the eastern countries of South America. The recur- 
rence of these epidemical cycles is not associated, however, 
with any definite periodicity ; and there is equally little 
regularity to be discovered in the return of the disease to 
particular localities. The scanty data that have been 
brought forward in support of a periodicity of that kind, are 
met by a much larger series of facts at variance with it ; 
and the data in question lose all significance as the conviction 
grows, on analysing them, that some of the items necessary 
to complete the periodical series do not relate to actual 
epidemics, but only to aggregations of sporadic cases. 

We have hero another thing peculiar to the manner 
of appearing of scarlatina, which distinguishes it from 
measles ; the latter occurs almost solely as an epidemic, the 
isolated cases of measles being either its forerunners or its 
scattered offshoots persisting for a time ; whereas sporadic 
cases of scarlatinal sichiess, in large numbers or small, have 
been observed a good many times. 

A third conspicuous peculiarity of scarlet fever is the 
variation in the intensity of the disease, as seen in the 
degree of mortality, which in some epidemics is almost nil, or 
from three to five per cent, of the sick, and in others thirty 

' Kostlin, in ' Archiv des Vereins fiir wissensch. Heilkde.,' 1865, p. 328. 
- Account in the 'Mittheil. des bad. iirztl. Vereins,' 1855, No. 9. 
^ Hildreth, in ' Amer. Journ. of Med. Sc.,' 1830, Feb., p. 329. 
* Shattuck, ib., 1841, April, p. 373. 


per cent, and more. This varying degree of severity in tlio 
disease is shown, moreover^ not only in the successive 
outbreaks following close upon one another at a given 
place, but also in the series of epidemics distributed over 
longer periods of time ; it comes out, too, in an equally 
striking way on comparing the intensity of the disease in 
the contemporaneous outbreaks of localities adjoining, or 
even throughout a wide area. 

"In the year 1801," says Graves,^ '^scarlet fever com- 
mitted great ravages in Dublin, and continued its destructive 
progress during the spring of 1802. It ceased in summer, 
but returned at intervals during the years 1803-4, when the 
disease changed its character ; and although scarlatina 
epidemics recurred very frequently during the next twenty- 
seven years, yet it was always in the simple or mild form, so 
that I have known an instance where not a single death 
occurred among eighty boys attacked in a public institution. 
The long continuance of the period during which 
the character of scarlet fever was either so mild as to require 
little care, or so purely inflammatory as to yield readily to 
the judicious employment of an antiphlogistic treatment, led 
many to believe that the fatality of the former epidemic was 
chiefly, if not altogether, owing to the erroneous method of 
cure then resorted to by the physicians of Dublin, who 
counted among their number not a few disciples of the 
Brunonian school. . . . The experience derived from 
the present epidemic [1834-35] has completely refuted this 
reasoning, and has proved that, in spite of our boasted 
improvements, we have not been more successful in 1834-35 
than were our predecessors in 1801-2.^' In a review of 
Armstrong's ' Practical Illustrations on the Scarlet Fever ' 
a Boston critic observes :^ " We will take this occasion to 
remark that not only during the last year (1819), but, with 
the exception of 1802, for more than thirty years past, the 
scarlet fever has not appeared under a severe form in this 
place. But the same has not been true in respect to some 
other parts of the country during the period above mentioned, 
and at former times this disease has been among the most 

' ' A System of CHuical Medicine,' Dubliu, i84;<, p. 493. 

2 « 

Now Eiigluud Jouru. of Med.,' 1820, July, p. 253. 


fatal scourges of New Englaud." Drake speaks to the same 
effect of the disease as it occurs in the central (Mississippi) 
valley of the United States.^ The history affords very 
many examples of great differences as regards benignity or 
virulence in the epidemics of scarlatina coexisting at several 
localities in the same neighbourhood. To refer to only a 
few of the more recent facts, we find evidence of this in the 
observations recorded of the epidemics of 1852 and following 
years in Wiirtemberg/ of 1853 in the Palatinate/ of 1855 
in Middle Francouia* and Upper Bavaria/ of 1855 and 1856 
in Sweden, and of 1857 ^^ Pennsylvania.^ 

§ 53. Influence op Seasons and Weathee. 

The fact that by far the largest portions of Asia and 
Africa, particularly their tropical and sub-tropical regions, 
have almost entirely escaped scarlet fever up to the 
present, has often been taken as warranting the conclusion 
that climatic influences play a prominent part among those 
external factors which determine the geographical distribu- 
tion of the disease. This opinion is entirely refuted by the 
proofs that scarlet fever has often been found epidemic in 
the tropical countries of South America ; and if it cannot be 
denied, as Drake^ first pointed out, and after him Minor^ 
and Sozinsky,^ that the States of the Union situated south 
of 33° have enjoyed a certain immunity in comparison with 
the Northern States, yet the reasons for that, as well as for 
the great rarity of the disease in the above-named regions 
of the Old World, are not to be sought, or at least exclusively 
sought, in circumstances of climate, the less so that in many 

1 L. c, ii, p. 596. 

- Account iu ' Wiiittemb. med. CorrespondenzLl.,' 1854, No. 26, p. 201. 

^ Account in 'Bayr. iirztl. Intelligenzbl./ 1854, p. 434. 

■* Eckart, ib., 1856, p. 450. 

'= Wibmer, ib., 1858, p. 327. 

6 i Transact, of tbe Pennsylv. State Med. Soc.,' 1858. 

" L. c, ii, p. 596. 

*> ' Scarlatina Statistics of the United States,' Cincinnati, 1875. 

9 ' Philad. Med. and Surg.' Reporter,' 1S80, Jan., p. 69. 



countries in cold or temperate latitudes, scarlet fever counts, 
as we have seen, among the rarest of diseases. 

And just as the diffusion of the disease in space does not 
depend upon climatic influences, so also does its time of 
prevalence remain uninfluenced by the season and the weather 
much moi"o than in the case of smallpox or measles, if 
indeed it be so influenced at all. In the accounts before 
me of scarlatinal epidemics in temperate latitudes, I find 435 
in which the time of prevalence, and the point of highest 
intensity, are given with some exactness. A tabular state- 
ment of them brings out the following result : 








. -" 



I. <u 


■3 a 




a Of 



H '>^ 

a H 

r H 


s -*± 

fci = 


♦^ a 




'J A !/i 

CO < 







3 =■ 


Scandinavia and Russia 8 

6 ... 











Germany, Holhiud, and , 

England . . '46 













France, Italy, and , 














North America 

























The disease has been epidemic, therefore, 178 times in 
winter, 157 times in spring, 173 times in summer, and 213, 
times in autumn ; or in 100 epidemics, there have been 29*5 
in autumn, 24*7 in winter, 24 in summer, and 21 '8 in spring. 
This conclusion, that the maximum falls in autumn and the 
minimum in spring while the prevalence in summer and 
winter is about equal, is confirmed by a second scries of 
statistical data showing the mortality from scarlet fever for 
the several seasons over a long series of years. 

Table of Deaths from Scarlet Fever. 


Seasons. 1 





London . 
Sweden . 

1 838-1 853 
1864— 1873 







3-4 '5 


Tlio perceutjige of dcatlis, accordingly, was : 

For London 32* i in autumn, 25*2 in summer, 22*8 ii> 
winter, 19*9 in spring. 

For Sweden 29*4 in autumn, 23*9 in summer, 24*6 in 
winter, 22*1 in spring. 

The result agrees, further, with the statements of the 
great majority of observers ; next to autumn they put 
summer and Avinter as the seasons of greatest prevalence, 
assigning a somewhat lower place to spring.^ 

It does not appear, at first sight, what may bo the cause of 
these diiferences in the frequency of scarlatina during the 
several seasons of the year ; one thing at least is clear, that 
we should not look for the reason in the influence of par- 
ticular hinds of weather. If some observers conclude from 
their collective experience that cold weather, particularly 
when accompanied by moisture, is especially favorable to 
the production of scarlatina, it must be kept in mind, on the 
other hand, that the disease has not only been prevalent 
over and over again during great heat and drought, but also 
that the epidemics occurring under those circumstances have 
reached their height precisely as the temperature rose, and 
have declined when the heat subsided and cooler weather set 
in j and further, that by far the larger number of observers 
altogether deny that the weather has any influence at all 
upon the origin and diffusion of the disease. 

As examples of epidemics during the strong heats of 
summer the following maybe mentioned: — 1759 at Lille," 
1769 at Eouen^ and Paris,''^ 1763 in Cephalonia,^ 1723 at 
Lyons," 1800 at Paris,'^ Wiirzburg,^ Liincburg,^ Plauen,^° and 

' Spring is given as tlie proper season of scarlet fever by only a few French 
and Italian observers, such as Simoniu for Nancy (' Recherclies topogr. et moil. 
sur Nancy,' Nancy, 1854, p. 281), Prion for Nantes ('Journ. gen. do med.,' 
1826, Sept., p. 350), and Menis for Brescia (1. c, p. 154). 

- Boucher, in ' Journ. de med.,' xi, p. 92. 

^ Lepecq, ' Samnil. von Beobachtungen iiber cpid. Krankheiten, &c.,' p. 290. 

" Desessartz, in ' Journ. de med.,' xlix, p. 538. 

5 Zulati, 1. 0. 

^ Gilibert, ' Adversar. med.-praet.,' Lugd., 1791, p. 184. 

7 Account in 'Journ. gon. de mod.,' ix, p. 182. 

^ Gutberlet, in ' Huf eland's Journ. der pract. Heilkd.,' 1S06, xxiii, pt. i, p. 29- 

^ Fischer, ib., 1801, xiii, pt. 4, p. 23. 
'" Schmoger, ib., 1805, xxii, pt. 2, p. 122. 


otlier places in Germany, 1814 in the Pracliincr district/ 
1819 at Zcll/ 1823 at Prague/ 1830 at Pittsburg (Pa.)/ 
1834 at Amsterdam/ 1838 at Charleston (S. Car.)/ and 
1847 at Dorpat.^ Epidemics coming to a heiglit as tlio tem- 
perature rose, and subsiding when the cold weather set in, 
were observed in 1778 at Birmingham,^ 1786 in London," 1791 
at Ciotat,^° 1822 at Fulda,^^ 1828 at Buer,^^ 1830 at Annaberg/^ 
1833 in Paris,'^ and 1846 at Smolensk.^^ 

Referring to epidemics in Denmark, Salomonsen has the 
following remark on the relation of the disease to the state 
of the weather :^'' — " For Epidemierne i dette Aarhundrede 
synes det altsaa at vaerc Kegel, at do kun vistc sig hos os 
vid en Temperatur, der var over den saedvanligo. I de 
cevrige meteorologisko Forhold kunne vi derimod ikke finde 
noget constant. ^^ 

§ 54. Unaffected by the Nature op the Soil. 

There is no reason whatever to suppose that conditions of 
the soil, sucb as elevation, configuration, or geological and 
physical characters, have the slightest influence upon the 
occurrence and spread of scarlet fever. Like smallpox and 
measles, it lias been found just as often in mountainous as 
in low-lying districts, in valleys as on tablelands and plains, 

^ Sazym.i, in * Oest. med. Juhib.,' 1829, n. s., i, p. 134. 

- Andreae, in ' Rliein. Jahrb. fiir Med.,' ii, pt. 2, p. 32. 

3 Bischoff, ' DaistoU. der Heilungsmetliode in der med. Klinik.,' &c., Prag., 
1825, p. 26. 

^ Callagliau, in 'Amor. Joiirn. of Med. Sc.,' i8ji. May, p. 71. 

'" Nicuwenhuys, in ' Transact, of the Prov. Med. Assoc.,' iv, p. 71. 

^ Logan, in ' Southern Med. Reports,' 1. c. 

? Jamsoa-Himmelstiern, in ' lligaer med. Beitriige,' i, pt. i, p. 144. 

8 Withering, 'Account of the Scarlet Fever, &c.,' Loud., 1779, p. 35. 

'J Sims, in 'Mem. of the Lond. Med. Soe.,' i, p. 388. 
w Ramel, in ' Journ. de mod.,' Ixxxviii, p. 169. 
" Schwarz, in ' Rhein. Jahrb. fiir Med.,' xii, pt. i, p. 75. 
'■^ Krcbs, in ' Heidelb. Iclin. Annul.,' 1833, ix, p. 137. 

'■■i ' Physikats-Berichte aus dem Kunigreich Sachsen v. d. Jahrou 1828-30,' 
p. 65. 
" Account in ' Gaz. dcs hopit.,' 1833, No. 129. 
li Metsch, in ' Med. Ztg. Russl.,' 1846, p. 319. 
^6 ' Udsigt over KjObenhavus Epidouiier,' Kjobeub., 1854, p. 38. 


on tlic most various formations wlictlier old or recent, on 
dry ground and on wet ; and if some localities and tracts 
of country liave been more severely visited than other 
districts near tliom at times when scarlet-fever epidemics 
have been general, yet the local circumstances in question 
give no clue one way or another. 

§ §5. Mildness ok 'Severity op the Type op Disease. 

Scarlet fever stows itself to be independent of climato, 
season, weather, and influences of locality, not only as 
regards its distribution-area, but also as regards its inten- 
sity, or tliG mild or malignant type of the e^ndcmic. Just as 
little, speaking generally, do hygienic defects arising from 
social conditions appear to exert any definite influence on 
the character of the sickness. In tracing the geographical 
area of the disease, I have already shown that in whatever 
tropical regions it is met with, just as in temperate latitudes, 
it prevails at one time mildly and at another time in a 
disastrous form ; the epidemics on the East Coast of South 
America, in the West Indies, and in Peru are examples. 
The two following series of observations show how little the 
benign or malignant type of the epidemic is influenced by 
the season of the year. 

Among the epidemiological data before me I find the 
season of prevalence and the type of the sickness given 
somewhat precisely for 265 epidemics. Of these 126 are 
given as of mild type, and 139 as severe;^ in winter there 
occurred 77 (34 mild and 43 severe), in spring 50 (27 mild 
and 23 severe), in summer 66 (30 mild and 36 severe), and 
in autumn 72 (35 mild and 37 severe). The percentage, 
accordingly, is as follows : 

Of 77 winter epidemics 44* 2 per cent, viild, 55"8 per cent, severe. 
„ 50 spring „ 54-0 „ 46-0 

„ 66 summer „ 45-5 „ 54-0 

„ 72 autumn „ 48-6 „ 51-4 

1 lu order to determine what constituted a "severe epidemic" I took either 
the express declaration of the writer or the rate of mortality, reckoning as 
severe all epidemics with a mortality of over 10 per cent. 


Thus the maximum of raalignancy falls in winter and 
summer, the minimum in autumn ; but the difference is so 
small that it need hardly bo considered. 

In Sweden, for the years 1864- 1873, the sickness and 
mortality from scarlatina were as follows : 

In the -winter months out of i6,i8S sick, 2869 died = i7'7 per cent, 
spring „ „ 14,716 „ 2749 „ =18-7 

„ summer „ „ 13,997 >. 2877 „ =200 

„ autumn „ „ 20096 „ 3415 „ =17-0 „ 

Here the mortality is greatest in summer and spring, 
while the minimum falls in autumn ; but there, too, the 
differences are so insignificant that no particular stress need 
be laid on them. We may therefore dismiss the notion, 
derived from isolated observations,^ that epidemics of scar- 
latina are of an especially severe type in changeable and 
damp weather, an idea already refuted, as we have seen, by 
the occurrence of severe epidemics during the dry and hot 
weather of summer. 

By other writers it has been sought to connect the 
severity of the epidemic with the low and damp situation of 
the affected locality, and with the injurious effects of pro- 
ducts of decomposition in the soil or in stagnant water ; and 
in this way an explanation has been furnished of the relative 
frequency of the disease in towns as compared with country 
districts. Thus, Cremen" would attribute the malignant 
character of the Cork epidemic of 1862 to the effects of 
joutrid effluvia (from bad drains, dung-heaps, &c.), which were 
perceptible in those parts of the town W'hero the poorer 
classes lived and to which the sickness was almost confined. 
Ballard^ points out that in the epidemics of 1857-68 at 
Islington the streets situated near the watercourse suffered 
most ; Andreae"*^ adduces the fact that the town of Zell 

1 Morris (' Lectures on Searlet Fever ') for Pliiladelpliia, Attenhofer (' Med, 
Topogr. von St. Petersburg,' Ziiricl), 1S17, p. 240) for St. Petersburg, Thucs- 
sink (I.e.) for the Netherlands, Gutbcrlet (' Hufeland's Journ.,' I.e., p. 102), 
from observations .at Wiirzburg,' 1 789- 1 803, and Wittni.ann (' Ehein. Jahrb. fiir 
Med.,' 1822, V, pt. I, p. 59) from observations made in Mainz and neighbourhood, 

» 'Dubh Quart. Journ. of Med.,' 1863, May. 

=» 'Brit. Med. Journ.,' 1869, Dec., p. 620. 

* L. c. 


suffered more in the epidemic of 1819 than the neighbouring 
mountainous districts ; Marchioli^ observes that during the 
Cremona epidemic of 1871 the only place near, that was 
attacked, was the village of Ricorsano, occupying a marshy 
situation, all the elevated and dry localities escaping ; 
Seifartli" remarks of the Langensalza epidemic of 1867, that 
the streets mostly affected were those near the churchyard 
where the soldiers that fell in the battle of 1866 Avere buried. 
Carpenter'^ gives several cases observed in and around 
Croydon from 1848 to 1870, which tell in favour of the 
injurious influence of putrid emanations on the course of 
the disease in particular individuals or in groups of persons. 
Mui'chison also," while ho admits that the fever had fewer 
victims in the densest and nnhealthiest parts of London than 
in the cleanest and most sparsely populated, still thinks that 
some weight should be laid on the unfavorable influences 
which effluvia from drains exert on the course of the malady. 
We have also to consider here the circumstance already 
mentioned, that scarlet fever is not only of more frequent 
occurrence and more widely spread in towns where those 
sanitaiy defects are most felt, but also that it is of a more 
malignant type than among the country people, — that the 
great centres of traffic are the principal seats of the disease, 
and of the disease in its worst forms. Thus, Radcliffe^ has 
shown that in England the mortality is greatest in London 
and in the north-western and northern counties (Cheshire, 
Lancashire, Yorkshire, Durham, Northumberland, Cumber- 
land, and Westmoreland), the centres of mining and manu- 
factures, while it is least in the southern and inland counties 
of Middlesex, Herts, Bucks, Oxford, Notts, Huntingdon, 
Bedford, and Cambridge, in which the population is more 

In all these cases, as in many others of a like kind, it is 
clear that we have to deal with an aggregate of injurious 
influences, the pathological significance of each of which can 
hardly be estimated by itself. As a general principle we 

^ ' Gaz. med. Lombard.,' 1872, No. 14. 

' 'Zeitsclir. fiir Epidemiologic,' 1869, n. s., i, p. 56. 

' 'Lancet,' 1871, Jan., p. iii. 

•" ' Lancet,' Oct. 15th, 1864. 

^ 'Transact, of the EpidemioL Soc.,' 1867, ii, p. 265. 


sliall liavo to admit for scarlet fever, as for most other 
epidemic diseases, tliat whatever lowers the power of resist- 
ance in the individual, raises not only his predisposition to 
take the disease, but also the risk to which his life is 
exposed by it. We find this laAV brought out in the circum- 
stances before named, and above all in those records^ Avhich 
prove the disease to have been severe and attended by high 
mortality in many epidemics among the proletariat, where 
want, misery, neglect, dirt, &c., along with defective or 
altogether deficient medical attendance, render the situation 
of the sick as unfavorable as it can be. But there cannot 
well bo any question of attributing to these defects a specific 
influence upon the type and character of the epidemics as a 
whole. The arguments of English observers, who have 
always given special attention to the point, are most con- 
vincing in this respect. Thus Withering, one of the earliest 
and best authorities on scarlatinal epidemics, states, on the 
authority of his Birmingham experiences in 1778, that the 
disease had raged severely in many elevated, dry, and airy 
localities, while the dwellers in low, damp, and ill-ventilated 
parts of the town suffered to a very slight degree or not at 
all. Graves, in his account of the epidemic of 1839 in 
Ireland,^ says : '' The nature of the disease did not appear in 
the least connected with the situation or aspect of the 
patient^s dwelling, for we observed it equally malignant in 
Rathmines as in Dublin, on the most elevated habitations on 
mountains as in the valley of the Liffey. It raged with 
similar violence at KingstoAvn and the neighbourhood of 
Killiney and Bray." Wood,^ in his account of the epidemic 
of 1835 at Edinburgh testifies to the same effect: "It is a 
remarkable circumstance that the fever extended nearly as 

1 See the epidemiological accounts by Cohn (in ' Casper's Wochenschr. fiir 
die ges. Heilkdc.,' 1833, p. 913) for Inowraclaw 1831, by the Medical Council of 
Rhenish Prussia (' Jahresboricht,' 183S, p. 42) for the department of Coblcnz 
1838, by Moller (' Archiv fiir i)liysiol. Hcilkd.,' 1S47, vi, p. 535) for Kclnigsbcrg 
1844-45, by the Wiirtemberg physicians (' Wiirttemb. nied. Correspdzbl.,' 1854, 
No. 26, p. 201) in 1852, by Heim (ib., 1864, No. 25, p. 195) for Tiittlingen, 
862-63, by Cremen (1. c.) for Cork same year, by Lievin (' Viertcljalirschrift fiir 
olfentl. Gesundheitspfl.,' 1871, iii, p. 369) for Danzig 1868, and by Otto ('Das 
Scharlachficber in Chicago, &c.,' Gottingcn, 1879, p. 19) for Chicago, i876.77. 

- 'A System of Clinical Medicine,' Dublin, 1843, p. 501. 

3 * Edin. Med. and Surg. Journ.,' 1837, July, p. 99. 


rapidly, proved as severe, and was as destructive of life in 
the families of the higher ranks, living in large houses, in 
open, airy situations, as in those of the lower, crowded 
together in small, airless dwellings, in narrow streets and 
lanes." In the report^ upon the epidemic of 1 868 in London, 
all the metropolitan Medical Officers of Health agree in 
stating that the well-to-do part of the population living 
under favorable conditions suffered as much as the poor, 
and sometimes more. The account of the epidemic there in 
1869-70 is to the same purport: *' The disease," says Whit- 
more in his report for Marylebone," "was by no means 
especially prevalent amongst the dirtiest and most destitute 
classes ; it principally occurred amongst children of the 
respectable poor, and more frequently than otherwise in 
houses where the sanitary conditions were by no means 
defective." In the report by Davies^ of the epidemic of 
1870-71 at Bristol it is stated: "Judging from the class of 
persons and houses mostly affected by the present epidemic, 
this disease has but little if any connection with general 
sanitary conditions. ... It has proved its fatal influence 
as readily in the well-situated and well-ventilated mansions 
of our healthy and rich subui'b of Clifton as in the crowded 
courts and badly-ventilated alleys of the more ancient parts 
of the city. Indeed, the old and hadly -ventilated courts 
enjoy a considerable immunity." Hillier* says : " This dis- 
ease does not confine its ravages to the dwellings of the 
poor, nor does it commit much greater devastations in ill- 
drained, badly-ventilated places than in those which are 
well provided with drainage and moderately supplied with 
fresh air. Hygienic conditions exercise less influence over 
its course than they do over most epidemic disorders. In 
the great majority of deaths from measles there are generally 
either unfavorable sanitary arrangements surrounding the 
patient, or the child was previously unhealthy ; deaths from 
measles, except in the case of unhealthy children, are rare 
amongst those in easy circumstances. The same cannot be 

^ ' Med. Times and Gaz.,' 1869, April, p. -^C)-. 
^ 'Brit. Med. Journ.,' 1870, May, p. 526. 
^ lb., 1870, Sept., p. 297. 
* ' Med. Times and Gaz.,' 1S62, 31st May. 


said of deaths from scarlatina ; it has cveu been asserted by 
some that this disease proves more fatal to the children of 
the rich and well-to-do classes than to those of the poor." 
Prior/ in his account of tho epidemic at Bedford in 1855, 
says : " There is nothing in these facts in the shape of clear 
proof that either proximity to the river or geological forma- 
tion influenced tho extension or fatality of the disease/' 
There, also, the well-to-do suffered equally with the poor ; and 
so far as relates to the notion that defective drainage has an 
unfavorable influence on the course of the disease, Prior 
states that *^ there was nothing in this epidemic to sanction 
such a belief/' 

I think that tho facts here adduced, to which I could add 
many more of a like kind, including my own observations at 
Danzig from 1846 to i860, will suffice to show that we are 
completely in the dark as to the conditions that make scar- 
latinal epidemics to assume a good or bad type. Science at 
the present day has to confess ignorance on this point, just 
■as Drake did when he said •} " of the causes or conditions 
which determine these remai-kable diversities of phenomena 
•and danger [in scarlatina] we are entirely ignorant." 

§ 56. The Virus op Scarlatina. 

Concerning the nature of the scarlatinal j)oison, its specific 
character is beyond all question, and like all other of the so- 
called morbid poisons, it may with good reason be taken to 
be an organised body. But all the inquiries and experiments 
hitherto — by Hallier,^ Coze and Feltz,^ Boning/ Balogh," 
and others — have not furnished any certain knowledge about 
it. The well-founded presumption of the organic nature of 
the virus of scarlet fever excludes the idea of an autochtho- 
nous pathogenesis : the disease never arises but in conse- 

^ 'Lancet,' i86y, Oct., p. 5;o. 

* ' Principal Diseases of the Interior Valley of North America,* Ciucimiati, 
1850, ii, p. 596. 
"* ' Jahrb. fiir KiDdcrheilkdo.,' i86.j, ii, p. 169. 
'' ' Gaz. raed. c',e Strasbour':,' 1869, Nos. i — 4. 
'" ' Deutsche Klinik.,' 1870, No. 30. 
6 '3Ied. Ccutral-Ztg.,' 1876, p- 625. 


quence of a conveyance of tlio specific poison, and the spread 
of the sickness is dependent on the fact that the virus, re- 
produced in the sick person and eliminated by him, forms 
new foci of iufection. 

§ 57. Oiac.iNAL Habitat Uncertain. 

At the outset of this inquiry wo found reason for believ- 
ing that no conclusion could bo arrived at as to the native 
habitats of scarlet fever, — from what points of the globe the 
disease had originally issued, or where it had subsequently 
become domesticated. So much only ono may affirm, on 
the strength of the historical facts above given, that the en- 
demic area of scarlet fever is a limited one, that at many 
parts of the globe the disease has never occurred except 
when imported, that it has been able, indeed, to exist in 
those countries for a longer or shorter period, but has died 
out in the end, and if it has reappeared it has always been 
necessary to assume a fresh introduction of the morbid 
poison. The reason why the continents of Asia and Africa 
have remained hitherto almost free from the sickness, not- 
withstanding many importations of it, does not admit of 
being explained ; the influences of climate, soil, or other 
conditions perceptible to the senses, afford at least no clue ; 
and just as little is the cause of the immunity to be looked 
for in the physiological characters of the natives of these 
regions, or, in other words, in the peculiarities of race. 
Pruner,^ indeed, states that so far as he knows, the coloured 
races are quite exempt from scarlet fever, but that opinion 
is certainly wrong. Scarlatina occurs, although rarely, among 
the negro population of Senegambia ;" and this infrequency 
is explained, not by any relative immunity of the negro race, 
but by the rarity of the disease there at all. Negroes in the 
United States suffer like the whites, and, it would seem, in 
almost equal proportion ; according to Frick,^ the proportion 
among whites and negroes in the Baltimore epidemic of 

1 L. c, p. 120. 

- See Moulin, ' Patliologie de la race Nesgre, &c.,' Paris, 1866, p. 22. 

' • Amcr. Journ. of Med. Sc.,' 1855, Oct, p. 321. 



1850-54 was I3'8 and io"8 iu 10,000 inhabitants. In 
Soutli America, following the accounts of Brunei/ Sigaud/ 
and others, the disease is equally frequent and of the same 
type among the coloured as among the white races ; Mante- 
gazza/ indeed, states that the Creoles suffer more than the 
whites ; and, that the red-skinned natives of North America 
(Canada) are at least not exempt, follows from Stratton's re- 
mark ;'^ " in epidemic scarlatina it appeared to me that the 
Indians were less susceptible of an attack than the whites." 

§ 58. Diffusion op the Morbid Poison. 

The vehicles of the morbid poison, conveying the malady 
from person to person and from place to place, have been 
taken to be the currents of air about the patient, or articles 
in that infected atmosphere which had taken up the virus 
eliminated from the sick. The distance to which the virus 
may be carried by the air cannot be expressed in definite 
figures ; there is evidence at least that the distance is a 
small one, the focus of infective action being often closely 
circumscribed, and the immediate neighbourhood free. It 
remains an open question whether this fact, as it stands, is to 
be explained by a loss of potency in the poison through 
diffusion and dilution, or on the hypothesis that the virus is 
a relatively heavy body which can be carried only a short dis- 
tance by the atmospheric currents. There are many 
instances truly classical, going to prove the conveyance of the 
'poison through the medium of infected articles. Thus, to give 
only a few of the more recent observations on this point, 
Heslop'' traces the spread of scarlatina iu the Birmingham 
Children's Hospital to the linen of children sick with scarlet 
fever being aired and made up in the same room with the 
rest of the house-linen; formerly the precaution had been 
taken to have the body- and bed-linen of scarlatinal patients 
washed outside the institution, and so long as that rule was 

' L. c, p. 42. " L. c, p. 209. 

3 ' Lettre, &c.,' i, p. 12. 

■• 'Edin. Med. and Surg. Jouni.,' 1849, April, p. 282. 
* 'Lancet,' 1870, Nov., p. 736. 


followed, tliere had never been any conveyance of the 
disease. Ogle^ also mentions similar cases where the disease 
had been communicated by linen from the laundry. He refers 
besides to a case which shows that the virus may cling to 
furniture. A husband and wife, having lost four children 
by scarlatina, removed for a time to another locality with 
their only surviving child ; they had the rooms that had 
been occupied by the deceased children thoroughly cleaned^ 
the walls re-papored, all clothes and bed-linen that had been 
used by the sick destroyed, and the furniture disinfected ; 
only two arm-chairs, of which the hair stuffing was torn, 
were overlooked in the cleansing operations. Ten weeks 
afterwards, the family returned to their house, and in 
fourteen days the child sickened of scarlatina. Petersen^ 
mentions an attack of scarlet fever in a young girl, who kept 
up a correspondence with a friend at a distance ; the latter 
had been suffering from scarlet fever, and several of her 
letters had been despatched during the period of desquama- 
tion. Many other examples of the disease being carried by 
letters are to be found in English writings ; and in none of 
those cases was there any other way of explaining the origin 
of the disease. 

Since the attention of the profession has been drawn to 
the communication of infective diseases by drinking water 
and milk, observations have not been wanting in support of 
that hypothesis for scarlet fever ; but whether they are con- 
clusive or not is open to question. Thus Pride^ calls atten- 
tion to the fact that in the epidemic of 1868 at Neilston, 
those attacked were mostly children who lived in certain 
houses drawing their water supply from polluted wells. 
Bell Taylor/ Welch,^ Buchanan,^ and others give particulars 
of scarlatina breaking out under circumstances which made 
it probable that the infection was produced by milk supplied 
by milk-dealers in whose families there had been cases of 

1 lb., Dec, p. 881. 

2 ' Ugeskrift for Laeger,'|i87i, iv, p. 309. 

3 ' Glasgow Med. Journ.,' 1869, p. 440. 

* 'Brit. Med. Journ,,' 1870, Nov., p. 489. 
5 lb., 1876, Aug., p. 225. 

Keport of Medical Officer of Privy Council, &c.,' 1875, ^- s.> ^o- vii, p. 72. 


Finally, as regards the often observed conveyance of scarlet 
fever by individuals who have themselves remained welly 
that is explained without difficulty on the assumption that 
their persons or clothes had become carriers of the morbid 
poison. The history of scarlatina abounds in examples of 
that kind, and it has generally fallen to the lot of medical 
practitioners to be the bearers of misfortune in these cases ; 
I can myself recall a case in my own experience where a 
physician brought the infection to his wife during her 
lying in. 


§ 59. Malarial diseases form a nosological group so closely 
I'elated to one another both in their pathology and thera- 
peutics, and also from the point of view of their history and 
geography, that we are entitled to regard them as modi- 
fications of a single morbid process ; and we may apply to 
that process a name which commits us, at least, to no theory, 
namely, the malarial process. 

Not many of the forms of people's sickness can be followed 
with so certain a clue as the malarial, through all inter- 
mediate periods up to the first beginnings of scientific medi- 
ciuQ, although the ancient and mediasval chronicles, medical 
and other, do not enable us to estimate the extent of their 
epidemic and endemic prevalence. It is, indeed, with the 
epidemiological records of the sixteenth century that the 
historical research begins ; and, for the geographical distri- 
bution of malaria, it is on the observations published since 
the commencement of the present era that we have practi- 
-cally to depend. Following up each of those lines of in- 
quiry, we come to recognise in the malarial process a form 
of disease which hardly -any other of the acute infective 
diseases can compare with in respect of its area of distribu- 
tion over the earth. Covering a broad zone on both sides 
of the equator, the malarial diseases reach their maximum of 
frequency in tropical and subtropical regions. They continue 
to be endemic for some distance into the temperate zone, 
with diminishing severity and frequency towards the higher 
latitudes ; in epidemic form they not infrequently appear in 
jet other regions ; and, in still wider diffusion with the 
character of a pandemic, also beyond their indigenous 


The geograpliical distribution of the malarial diseases 
stands, therefore, in a certain definite relation to the latitude ; 
and, in correspondence with that principle of dilTusion, we 
shall find the most suitable course of investigation to be one 
proceeding from the equator to the poles. 


Africa. — First and foremost, we meet with one of the most 
intense malarial regions of the eastern hemisphere in the 
tropical 'part of tlie continent of Africa and the islands adjoin- 
ing thereto. In the basins of the Senegal} and Gamlda" the 
disease is enormously frequent and malignant, equally on the 
marshy coasts and river banks and in the relatively dry 
regions of the upper river basin. Next, over the whole 
Guinea Coast^ from Sierra Leone down to Cape Lopez, but 
more especially in the basins of the Niger^ (Benin and the 
Slave Coast) and the Gaboon f and, further, on the coast of 
Sierra Leone,'' the Ivory^ and Gold^ Coasts, and in the ad- 
joining islands of Fernando Po^ and St. Thomas.^'^ 

For an approximate estimate of tlie frequency of the disease in these 
regions, tlie fact may suffice that among 15,469 negro troops located in 
the three English stations of Gambia, Sierra Leone, and the Gold 
Ooast (including Lagos) dm-ing 1859-75, there occurred 49S3 cases of 
malarial fever ; or, in other words, 32 per cent, of the troops (native) 

^ Thevenot, p. 258, Bcrville, Leblanc, Dutroulau, p. 248, Beal, Borius (I), 
Mondot, p. 12, Gauthier, pp. 16, 18, Chassaniol, Barthelemy-Benoit, Mahe, 
Chabbert, Thaly, Bourse (I), Serez, Bcrenger-Feraud, Leonard, Carboimcl, Ver- 
dier, Dudon, Def aiit. (The particulars of these and all subsequent references will 
be found in the syllabus of the literature at the end of the section). 

' Hoe, Ritchie (April), p. 323, Rey (I). 

^ Bryson, Kehoe, Daniell (II), p. 154, Ritchie (April), p. 324 (May), p. 402 
(June), p. 515, Heyne, Lawson. 

" Isoard, OUlfield, McWilliam, p. 180, Pritchett, Quintin, Feris (I). 

5 Touchard, Griffon de Belny, Monncrot, p. 14, Bourse, p, 38, Rouvier, 

•"• Boyle (I), p. 123, Clarke (I), Gore. 

' Legraiu, Jubelain, Guergueil, Forne, Michel. 

** Gordon (1), Luekc, Gardiner in 'Brit. Army Med. Reports,' v, p. 323, 
Moriarty, ^lichcl. 

5 Daniell (II), p. 154. '» Id. (II), p. 189. 


suffered from that disease. The amount of sickness among the Euro- 
pean population was naturally much greater. 

There is better health from Capo Lopez downwards, and 
along the Congo Coast^ where the regions of more intense 
malaria are met with only at intervals, as in the swampy 
neighbourhood of Benguela ; ^ and this exemption from mala- 
rial disease becomes more and more marked the nearer we 
approach the Gape of Good Ilope,^ which itself enjoys, along 
with St. Helena, an almost complete immunity from the en- 
demic fever. The same exemption obtained, up to a few 
years ago, in the islands of Reunion'^ and Mauritius,^ situated 
within the tropics ; but since 1866, centres of intense malaria 
have developed in these colonies under the circumstances to 
be afterwards mentioned. 

Among a total of 84,814 English troops maintained at the Cape 
during 1818-36, there occurred 1632 cases of malarial fever, a rate of 
sickness amounting to 1*9 per cent. ; but by far the larger part of all 
these cases were troops from India or China (and in 1867-75 from 
Mauritius) in whom the fever had recurred ; in the years when there 
was no such influx, the number of cases was exceedingly small. At 
St. Helena fi-om 1859 ^^ 1869, seven cases of intermittent fever 
were observed among 5462 English troops. In the Mauritius, the 
number of admissions for mahu-ial fevers in 1812-36 and 1859-66 
amounted to 262, or 0*4 per cent., and there also the disease occurred 
almost exclusively among such of the troops as had been transferred 
from China or India shortly before; but in the period from 1867 to 
1875, or after the disease had developed in the island, 6970 admissions 
occun-ed among 6084 men, and of these there occurred, in the first 
three years (1867-69), 5048 admissions among 3201 men. Of this 
frightful epidemic, further particulars in the sequel. 

A second great malarial region of the African continent is 
formed by the East Coast' from Delagoa'' Bay upwards along 
the littoral of Sofala, Mozambique,'^ and Zanzibar ;^ the trust- 
worthy accounts of travellers^ place it beyond doubt that the 

' Moreira, Tams, Bastos, Ritchie, (May) p. 411, Magyar (I), 450, Hugiot. 
^ Falkenstein, in his account of the Loaugo Coast. 
3 Friedel (II), p. 112, Egan. 
■• Barat, Bassignot, Lacaze. 

* Allan, Tessier, Monestier, Rogers, Lahonte. 

* Allan, Boteler. 
' Roquete. 

8 De la Peyre, Ruschenberger, Semanne, Lostalot-Bachoiie. 
^ Livingstone, Miller, Fritsch. 


foci of malaria there extend far into the interior, from tlio slioros 
of tlie Zambesi, Scliirc, aud Rovuma, and beyond Lake Ngami 
to the uortLern border of the Kakihari desert. Not less 
common and pernicious is the disease in the Comoros^ and in 
Madagascar," where the north-cast coast only, and the 
mountainous part of the interior, enjoy more favorable 
conditions of health. The extensive plateau of Somali Land, 
owing to its generally elevated position, the dryness of 
the soil, the absence of swamps on its thinly wooded 
coast, and the circumstances of its climate, probably deserves 
the character for compai'ativo healthiness which certain 
travellers have given it. Also in those parts of Ahyssinict? 
that are subject to the same influences, malarial diseases 
occur only to a modei'ato extent and of a relatively benign 
typo ; this holds good for the strip of coast (mostly 
narrow), with the exception of a few marshy points such as 
Massowah (which is almost uninhabitable for Europeans on 
account of its malaria),'* as well as for the whole west coast 
of the Red Sea generally/ and it holds good also for the Abys- 
sinian highlands ; while malarial diseases are endemic in 
their most pernicious forms in the narrow, densely-wooded 
and damp river valleys, in the swampy flats of Scraii, Lower 
Samen, &c., as well as on the shores of the Takazze aud 
of Lake Zuaio. 

The countries of which we have just been speaking form 
the eastern portion of a third great malarial region, which 
extends from the western slopes of the Abyssinian highlands, 
across Nidjia,'^ and a great part of the Soudan (as much of it as 
is known), aud through the marshy flats of Kordofau and 
Darfur as far as Lake Tchad (whose shores are the seat of 
the worst kind of fever), and probably beyond it as far as 
the elevated plains to the west. In Nubia the chief endemic 
scats are the banks of the two arms of the Nile, more espe- 

^ Curtis, p. 26, Dutroulau, p. 42, Grcuet, Foncervlucs. 

" Rochard, DauUe, Dutroulau, p. 239, Panou de Fagmoreau, Chabbert, Viusou 
(I), Davidson, Borius (HI), Horchgrovink. 

3 Aubert-Roclic, Harris (I), iii, 165, Pruucr, p. '356, Courbou, pp. 15 — 30, 

" Blanc. 

^ Aubert-Kofbe, Coulson. 

^ Voit, Pruucr, p. 356, Griesiugcr, Hartmaiiu (1). 


cially Khartoum situated at their confluence, and the Nile 
valley from that point down to Dongohi. Thou comes a 
region free from malaria, including- the northern parts of tho 
Dongola steppe and the rocky plateaus of that country as 
well as Upper Egypt, and the greater part of Middle Egypt; ^ 
that again is succeeded by a malarial zone which includes 
the low-lying province of Fayonvi in direct connexion with 
the Nile valley, and follows the river from Cairo to the shores 
of the Mediterranean, becoming broader as it advances north- 
wards, and extending more particularly over as much of 
Lower Egypt as is watered by the Nile. 

In Tripoli the basin-shaped province of Fczzan, abounding 
in salt lakes, together with tho oases, is stated to be the seat 
of pernicious endemic malarial diseases ; in Tunis^ also they 
are prevalent under the same circumstances. Finally, wo 
meet with a very extensive region of malaria on African soil 
in Algiers.^ The coast zone is here tho headquarters of tho 
disease. Among pai'ticular coast localities there are : in the 
Province of Constantine, — Bona, Philippeville, and Gigelhy ; 
in the Province of Alger, — the plain of Metidja, Alger, 
Blidah, Koloah and Tones ; in the Province of Oran, — Mosta- 
ganem, Oran, Ain-Temouchen, and others. But malarial 
diseases are also widely spread on the uplands of the Gi'oater 
and Lesser Atlas, on the banks of the Seybus, in Con- 
stantino, Setif, Batna (Province of Constantino),* in Medeah, 
Miliauah, Teniet-el-Had (Alger), ^ Tiaret, Mascara, Sidi-bel- 
Abbes, Saida, Tlemcen (Province of Oran),*' and in many 
oases of the Great Desert, such as Biskara, Tuggurt,'^ 
Ouaregla,^ and Lagouat.^ From those disease-centres, we 
pass to the great malarial region of the Soudan. According 
to an approximate calculation, the yearly number of admis- 

1 lb. 

- Ferrlni, p. 201. 

3 Maillot, p. 265, Pei'ier, Furuari, Laveran (I), Langg, Jacquot (I), Espauet, 
Beaunez, Bcrtheraiid (I, II), Cattclonp (I), Haspel (II), p. 151, Arniaud (I), 
p. 64, Philippe, Lcclerc, Bertrand, Gaucher (I, II). 

•• Worms, Guyou (I), Antouiui (I, II), Goudineau, Corne, Bedle, (juesnoy, 

* Villette, Berthcraud (III), Fiuot, Durand, Laveran (II), Serizlat, Claudot. 

6 Guyon (II), Marseillhan, Cambay, Froussart, Sourier et Jacquot. 

' Audct. 3 Creissel. ^ Bachon. 


sions for malarial diseases among the French troops in 
Algiers amounts to about one half of the admissions for all 
diseases whatsoever occui-riug among them. 

Asia. — We come next to the malarial regions of the 
tropical and sub-tropical parts of the Asiatic continent and 
the islands belonging thereto. Among those Arahin} 
takes a prominent place. In contrast to the western shore 
of the Red Sea, which is little infested by malaria, there is 
a region of very considerable malaria in the flat marshy strip 
of coast of the Hedjali (especially at Jeddah and Yembo)/ 
and in Yemen, from Jisan downwards to Mocha. Aden, 
situated at the southern extremity of this coast, is free from 
endemic malarial fever ; "^ and, from the accounts of travellers, 
the sandy plateau of the interior should also enjoy favorable 
sanitary conditions. On the other hand, the disease prevails 
in its worst forms on the south coast, especially in Muscat,'^ 
along the marshy shores of the Persian Gulf and the adjoin- 
ing islands (as at Bassadur in the island of Kishin"), as 
well as in a wide-spread endemic in the valleys of the 
Euphrates and Tigris from their mouths upwards throughout 

In Syria' we meet with extensive regions of malaria in 
the damp valleys of the Lebanon (equally in the valley of 
Beka, situated at a height of 1200 metres, and in the valley 
of the Jordan near the Dead Sea) ; further, at Jerusalem,'* 
Damascus, Aleppo,^ and other inland places, but especially 
in the coast localities, in Gaza, and up the coast to Jaffa, 
Tyre, Sidon, Beyrout,^" Tripolis, Acre, and Skanderoum. 

^ Aubert-Eocbe, Pruiier, p. 356, Palgravc. 

- Courboii, p. 67. 

3 HowisoD, Courbon, p. 59. From 1863 to 1S68 ami from 1871 to 1872 tbcre 
occurred among a total of 5219 Englisb troops at Aden, 374 admissions for 
malarial fever; at least 100 of tbcse have to be deducted as belonging to a regi- 
ment moved from Eombay, so that the rate of malarial sickness in Aden itself 
amounted to about 5 per cent, of the garrison. 

' Lockwood, Evatt. 

'' Rozario. 

^ Floyd, Wagner (I), Hyslop. 

' Pruner, p. 356, Kichanlson (I), Kafalowitscb, Riglcr (II), p. 376, Wortibet. 

** Toblor, p. 32, London. 

3 Guys, p. 63. 

'" Yates. 


From these centres the malarial region extends to the soil of 
Asia Mimr,^ from Adana and Tarsus along its south and 
west coasts (including Smyrna)/ the marshy banks of the 
Scamander, the plain of Troy/ and along the coast of the 
Black Sea, from Sinope, around the Gulf of Iskimio and 
Broussa to the Dardanelles. The accounts of travellers are 
too slight to enable us to say how far inland the disease is 

The table land of Armcniay^ with the exception of a few 
points, and the central mountainous region of Transcaucasia 
(Grusia)^ are little subject to endemic malaria; on the other 
hand, it is prevalent to a great extent on the marshy steppe 
of the Kuban, in the damp valleys opening towards the 
Black Sea, on the banks of the Terek, especially in the 
neighbourhood of Kisljar, at low-lying places in Dagestan, 
but in its very worst forms in the valleys of Abchasia, 
Mingrelia, Guria, and Imerctia, in the valley of Alasan, on 
the Mugan steppe, on the banks of the Kura as far as 
Lenkoran, as well as in the plain watered by the Araxes. 
From that point the malarial region extends along the 
marshy shores of the Caspian to Persia,^ where endemic 
malaria is met with in the pi'ovinces of Gliilan and Mazen- 
deran (Asterabad), in the valleys of the Attrek and Gurgan 
opening towards Turkoman territory, at several points on 
the plateau of Teheran, but of the most pernicious kind on 
the shores of the Persian Gulf, especially in Bushire.'^ 

Among the more considerable malarial regions of the 
continent of Asia we have to include Bcloochistan and Afghan- 
istan / the endemic fever is met Avith in these' countries 
equally on the swampy coast margins, as in Seistan abound- 
ing in salt marshes, in the lofty and dry Kelat, in the 
marshy plain of Dcdar, and in the Bolan and Kandge Passes 

1 Black (11), Uoeser, p. 31, Thirk, Pruuer, p. 356, Riglcr (II), p. 376, West. 
■' Clarke (II). 
3 Vircbow (II). 
■• Wagner (I). 

5 Hirtzius, Mironow, Tschetyrkiu, Reinhardt (I), Kaputschinski, PopofP, Moro- 
schkin, Krebel, Liebau. 
« l?ell, Polack. 
7 IMiller, Evatt. 
« Hunter (I), Thornton, Hartlalll, Cook. 



braucliing- from it, aud, further, iu Kaudaliar aud iu the 
ruouutaiu valleys of Cabul and Jelalabad. The last of these 
joins on to the great malarial region which extends over the 
northern plain of Hindostan, from the Punjauh through 
Sind and part of the Bombay Presidency, the North-West 
Provinces and Bengal, correspondiug respectively to the 
basins of the Indus and Ganges. 

To estimate the amount of malarial disease in the several 
great territorial divisions of India, the following statistics, 
gathered from the returns of sickness among the British 
troops (Europeans) quartered in them, will afford a sufficient 
basis •} 

Table of Admissions for Malarial Fever among European 

Troops in India. 



Total imniber of 

Admissions for 
Malarial Fevers. 


Bengal (including ") 
Noi-tb West Fro- [ 
vinces) . . J 




i860— 1875 
i860 — 1875 
i860 — 1875 

f 752.4 '9 









While, therefore, the average sickness from malarial fevers 
nmong European troops in India amounts to 41 per cent., it 
is as high as 46*6 in Bengal and the North-West Provinces, 
and as lyw as i4'i in the Madras Presidency, and it almost 
reaches the former figure in the Presidency of Bombay. 
Calculated on the total admissions for all forms of sickness, 
malarial fevers amount to 61 per cent, in the Bombay 
Presidency, 55 ])er cent, iu Bengal aud the North-AVest 
Provinces, and 35 per cent, in the Presidency of Madras.^ 

^ The tiiLk's arc compiled from the ' Army IMedical lleports,' published 
annually by the English (iovernment; iu making use of these reports I have 
exercised the greatest cautiou, aud have disregardtd the earlier of them, which 
are less reliable. 

' Compiled by Macpherson, iu the 'ludiau Annals of Med.,' 1858, Jan., ix, 
p. 227. 

•* Diiy, ib., US50, Jan., xi, p. 72. Tor the distribution of malarial diseases 


This enormous nmouut of malarial disease iti the Nortli- 
Wost Provinces^ and in tlio Presidencies of Bengal and 
Bombay is cliiefly attributable to the endemic prevalence of 
the disease in the basin of the Indus, where the disease is- 
met with over a vast area in highly pernicious forms, both in 
the upper part of the river system, Pcshawnr^ Cashmere, 
and the Funjanh^ and in the State of Sind'' belonging to 
the lower basin. The disease occurs to a moderate extent 
on the dry sandy soil of Catch/ while a region of intense 
malaria is formed by the jungle-covered and swampy plain 
of Guzerat.*' Proceeding eastwards we find malaria endemic 
on the hilly plain of Maiwar/ which is free from marshes,, 
.and in Malwa ; while it is in general more rarely met with 
on the barren sandy soil of the Rajpoot States. A focus of 
very intense malaria is met with, again, in the swampy 
slope which extends, under the name of the Terai, along the- 
southern base of the Himalaya, through the provinces of 
Garhwal and Kumaon, and the State of Nepaul, to the 
borders of Lower Bengali and far into the valley of the 
Ganges. In the upper regions of the Gangetic valley itself, 
such as the districts of llohilkund, Allahabad, Sirhind, and 
Oude, the endemic foci of malaria ai'e less frequent,^ although 
severe epidemics of malarial fever have often occurred. On 
the Ganges the malarial region proper begins at Benares, 
where the flat river-banks are exposed to annual inundations, 
and it extends thence through the eastern part of the North- 
West Provinces (the fruitful valley of Tirhoot^°), and through 
Lower BengaV^ where, next to the delta formed by the 
Hoogly'^ and Ganges, the chief scats of the disease are the 
marshy province of OHssa^^ the richly-watered plain (marshy 

throughout India in general see Henderson (T), Grierson, Annesley, pp. 33, 513, 
Morehead (I), p. 20, and Milroy. 

1 Murray (III). ^ Kiiinis. ' Moorcroft. 

* Lord, Don, Inglis (II), Campbell, Collier, Kinnis. 
^ Winchester, Moore, Kinnis. 
" Gibson (I), Inglis (I), Jackson (I). 
' Ewart. " Curran. 

3 McGregor, pp. 15, 245, Jackson (II). 
>o Evans (I), Tytler. 

" Martin, Twining (II), p. 250, Macpherson (I, II), Fleming, 'Army Med.. 
Rep.,' 1 86 1, p. 216, Forbes (I), Goodeve (I). 
»=> Sutherland. " Sterling, Shortfc (I). 


in its uortlicrn parts) wliicli descends between the Ganges 
and Bui-liampootra from tlio slopes of the Himalaya to the 
coast, and the flat swampy banks of the Burliampootra in 
the upper part of its course where it traverses the State of 

A point of especial interest for the history of malarial 
disease in India is raised by its endemic occurrence on the 
tahle-land of the Deccan." These fevers occur even in the 
mountainous countries of Chota Nagpore and Goudwana, 
sloping on the east towards Orissa and on the west joining 
on to the Vindhya mountains, and there forming the boun- 
dary between the Deccan and the plain of Hindostan ; and 
it is not only in the alluvial valleys, covered with jungle 
vegetation, or in the swampy valleys, that the fevers occur, 
but also, under the name of " hill-fever,''^ on the absolutely 
dry soil of elevated points. It is those very hill-fevers that 
make up the greater part of the endemic malaria of the 
Madras Presidency ^ The coast belt of that Presidency, per- 
fectly flat, and for the most part sandy and scantily watered, 
is the jDart least affected, the disease being met with only at 
several scattered points, Masulipatam,^ Nellore, Madras,^' 
Pondicherry,'^ Tranquebar,^ and other places on the Coro- 
mandol coast, where artificial irrigation, canals, or jungle 
plantations exert an influence special to the locality. It is 
the mountain region that here forms the proper habitat of 
the malarial diseases, particularly the hilly zone of the 
Northern Gircars,^ and the table-lands of Bellary and 
Mysore^^ with the notorious fever-bed of Seriugapatam.-^^ In 
the southern division of the Pesidency the habitat of malaria 
is in the deep valleys, damp and covered with rice-fields or 
jungle, in the districts of Trichiuopoly, Dindigul, Madura 
and Palamacotta, beyond which the endemic foci of malaria 
stretch far up into the hills. The Malabar Coast and all 

1 Leslie, McCosh. ' Staples, Hanimli. 

^ Brctou (I), Dunbar, Goodeve (II), Hughes aud Audcrsou, Godfrey. 

•* Geddes (II), p. 87 ff, Balfour, Day (III), p. 74, 

5 Murray (I), Geddes, 1. c. « Cornish (July), p. 83, Shortfc. 

' Huillet. 8 Kuhde. 

9 Wright (I), Macdonnell, Heyne, Smith (I). 
1" Eyre, Day (I), 1856, April, p. 571 ; 1858, Jan., p. 55. 
" Nicoll, Geddes (I). 


the western littoral belonging to the Bonihay rrcsidcncy^ 
is much more unhealthy than the east coast. Here also 
there is only a narrow margin of plain, but it is richly 
watered, abounding in woods and brackish lakes, marshy in 
part, or subject to periodical inundations, and therefore 
extensively malarious except at the more elevated and dry 
localities, such as Cananore, Tellicherry, and Calicut. 
Among the most important malarious regions of this zone 
are Manr/alore, and the broad littoral territory of Candeish' 
at the mouth of the Tapti ; but the disease is met with 
besides among the hills and valleys of the Wester7i Ghdts^ 
from Balgam^ upwards through the territories of Savant- 
Warri,^ Kolapore,'' Rutnagherry,'^ Sattara,^ and Poona,^ to 
Ahmednuggar and Aurungabad.^" 

Among Asiatic countries in which malaria is severe we 
have further to include Ceylon?^ The disease in that island 
is endemic not only on the coast, but also in the mountainous 
regions of the interior, even at Njuwera Ellija, situated at a 
height of 2000 metres [6000 feetj. Another malarious 
territory is formed by the richly- watered plains and the hilly 
countries of Lower India, where the fevers occur endemically 
in their severest forms in Chittagong^^ and Araccan,^^ in the 
upper and lower basins of the Irawaddy {Burma and Pegu),^^ 
at the mouth of the Salwen {Moidmein and Martahan) ^^ in 
Malacca}^ and the neighbouring islands, in the lower valley 
of the Monam, especially at Bangkok, and in the plains of 
Siam and Cochin CTiina^'^ abundantly watered by the Cam- 
bodia and Saigon rivers. Endemic foci of malaria are met 
with also in wide distribution throughout the Indian Archi- 
pclago,^^ especially in the Nioohars,^^ on the western and 
southern coasts of Sumatra^'^ (particularly Singkel, one of 

^ Kinnis, Arnott, Report in ' Bombay Med. Transact.,' n. s., vii, p. 252. 
2 Williamson (I). 3 Gibson (II). ^ Inglis (I), Waller. 

^ Kearney. <* Broughton. '' Crespigny. 

s Young (I). Gibson (II). '" Young (II). 

^^ Marshal (I), Cameron. ^* Maedougall, Beatson. '^ Burnard, Stevenson. 
'* Walsh, Dawson (I), Murchison, Stewart. ^ Day (IV). 

's Ward and Grant. 

'? Richaud, Fournier, Olivier, p. 55, Thil, p. 18, Veillard, Bernard, Morani, 
Danguy, Breton (II), Jacquet. 
1^ Heymann, Popp, v. Leent (I). '" Fontana, p. 57, Steeu-Bille, i, 244, 
■•'" V. Leent (IV). 

208 GEoaiiArniCAL and uistoetcal pathology. 

the unlioaltliiest places in the tropics^ Padang and the Bay 
of Pulo), in Banlut) and the small islands near it, in Java,^ 
especially its northern and western coasts (Batavia, Onrnst, 
Biutcnzorg,^ Samarang,'* Sourabaya, Madura, and Banju- 
wangi"'), in Bali, in Borneo, especially on the east and south" 
coasts, and to a lesser extent on the west/ on the east coast 
of Celebes and in the Moluccas, particularly Amboina, 
where a focus of intense malaria has developed in more 
recent times f the Andaman Islands belong also to the 
malarious spots of this part of the world.' On the other 
hand, we have to note certain points which enjoy a compara- 
tive immunity from malarial fever ; such as the north coast 
of Gelehes (Macassar and Koma), Ternate,^^ the flat banks of 
the Palcmbang in {Sumatra, the archipelago of Riouw- 
Lingga,^^ and Manilla?" 

Australasia and the Bac'ific. — An extremely interesting 
contrast to this wide prevalence of endemic malarial disease 
in India and the Indian Archipelago is afforded by the state 
of matters in the Australian Continent and throughout Poly- 
nesia. Truly endemic seats of malaria are met with there 
on the coast of New Guinea, according to the accounts of 
Dutch physicians, but nowhere else. Cases of malarial fever 
are said to have been often observed also in some of the small 
island-groups, such as the New Heh'ides,^^ and the Tonga 
Gronp}^ The continent of Australia}^ again_, so far as 
it has been hitherto settled by Europeans, pai*ticular]y 
its southern and eastern coasts, with Tasmania,^^ enjoys 
an almost absolute immunity from those diseases ; and 
that applies also to New Zealand?^ according to the unani- 
mous reports of observers, as well as to New Caledonia}^ 
and the Fiji,^^ Samoa,"'^ Wallis,'^ Society,'" Gamhier^ 

' Hollander. ^ Engclbroniier, Pecqueur, p. z^. ^ Swaving. 

'' In 'Arch, de mod. nav.,' 1868, Dec, p. 406. 

5 lb., 1868, Feb., p. 85. *= V. Leant (II). " Eeedcr. 

** Epp, Lecocq, v. Hattcm (I, II). » Hodder. 

'" V. Ewyk, V. Hattem (III). " v. Overbeck. '}- Taulier. 

» Bennet (I), De Ilochas, p. 15. " Wilkes (III), p. 32. 

1* Richardson (II), Bourse (Ilj. '* Dempster (I), Scott, Hall. 

'7 Johnson, Thomson (I), Bourse. 

'8 Vinson (II), p. 16, De Rochas, p. 15, Bourgarel, Charlopin, p. 16. 

'' Mcsser. "" Turner, Wilkes. *' Raynaud. "^ Dutroulau, p. 56. 

*^ Account in the 'Arch, de med. nav., 1876, July, p. 12. 


tind Hawaiian Islands} Bruuet^ wlio lived for five years in 
various parts of Oceania, states that lie did not observe a 
single case of malarial fever during that period. The ex- 
emption from malarial diseases of Australia and Oceania 
affords some important indications for arriving at the patho- 
genesis, and I shall I'eturn to them in the further course of 
these inquiries. 

We find the statements here made to be confirmed, for several of the 
above-named places, by the statistics of sickness among the British 
troops in the Australian Colonies and in New Zealand. Among 6786 
European troops in Australia from 1859 ^^ 1866 there were 31 cases of 
malarial fever ; and among 43.578 troops in New Zealand over the 
same pei'iod, there were iSi cases. But those cases occurred only 
among bodies of troops who had been brought direct from India, 
and had doubtless acquired the fever there. For the years 1867-69, 25 
cases were observed among 4491 European troops in Australia and 
New Zealand, and a single case among 3302 black troops. 

China and Jajyan. — The last malarial region on the conti- 
jient of Asia, and one of the most intense, is met with in 
the tropical and subtropical parts of China." Not only are 
there foci of malaria on the coast, among which Macao, Hong 
Kong,^ Canton and neighbourhood, Tai Wan (Formosa), Chee- 
Foo/ Shanghai,^ Chusan, and Tien Tsin may be mentioned 
as especially unhealthy, but they exist also in the interior, 
where, as Wilson states, the disease occurs along the course 
of the rivers as extensively and in as severe forms as on the 
coast, and where, as he adds, it exerts an influence more 
pernicious than in the malarial regions of India. More 
pa,rticnlar accounts of this endemic prevalence of severe 
malaria in the interior of China have not come to my know- 
ledge, except for Pekiu, and more especially for its vicinity.® 
Pernicious malarial fevers are said to be met with besides 
•on the coast of Corea and in the southern parts of Man- 
chooria, particularly Fungkiang.' On the other hand, in 
the Russian settlement on the island of Vladivostock (43*6° 
N.), it is stated by Manrin (following Dr. Aloproff, the Russian 

' Chapiu, Gulick, Le Roy de ilerieo irt (I). 

- "Wilson (I), pp. 20, 49, 12;, 130, Lj Roy (II), Gordou (II), Kocbefort, Dud- 
^eou, Duraiid-Fardel. 

» Mucpbersou (III), Dill, Smait. •» Rochefort. 

= Duburquoy, Hendersou. <= Moracbo, Rocbefort. •" Watson. 



physician of the station) tliat no case of malarial fever liad 
occurred within a period of five years. 

From 1859 to 1866, among 20,858 Britlsli troops (Europeans) stationed 
at Chinese ports, tlicro occurred 11,620 cases of malarial sickness, or 
55*7 per cent. ; in the years following, from 1867 to 1875, the propor- 
tion of malarial sickness was 2203 among 7584 European trooj)Sj or 
nearly 29 per cent., and among black troops 1687 out of 4366 men, or 
38 per cent, of the effective force. 

As to the endemic occurrence of malarial fevers in Japan, 
there are merely occasional notices from Nagasalci,^ Yoko- 
hama/ and Jeddo/ and more particularly from the islands 
of Sikokf and Kiushiu^ situated in the south ; but it Avould 
appear that the disease occurs only to a moderate extent 
and in its milder forms. 

Among 3067 British troops stationed at Japanese j^orts from 1864 
to 1867, 536 cases of malarial fever were observed, but almost all of 
them among troops that had come from China ; in the years from 1868 
to 1 87 1 the number of admissions for malarial fever fell to 22 among 
2476 men. 

Respecting other countries on the continent of Asia situ- 
ated within temperate or cold latitudes^ there are only a few 
references to the occurrence of malarial diseases at certain 
places in Siberia, such as the mines of Smeinogorsk (51 '9° 
N., district of Koliiwen)/ Barnaul/ and the Barahinsky 
Steppe, which abounds in marshes and salt lakes." 

Burope. — From the point last mentioned, which joins on 

directly to the Kirghiz Steppe, we pass to European soil by 

way of Russia in Europe, and therewith enter upon a wide 

region of malaria, which extends from the Steppes of Asia 

to the Steppe lands of the Caspian, follows the course of the 

Volga through Astrakhan,'^ and includes the central Caucasian 

plain and the countries bordering the Black Sea on the 

north, Taurida,^ the Crimea, with the notorious valley of 

Inkermann,^ Gherson,^^^ and Bcssarahia^^ the basins of the 

Dnieper and Dniester, as far as Elcaterinoslav^" the JJhraine^^ 

and Volhynia^^ as well as Moldavia, Wallachia, Bulgaria, and 

' Friedel (I), p. 24. - Duburquoy, p. 17. ^ "Wcrnieh, Magct. 

4 Rex. s GMor. " Woskosoiisky. 

7 Herrmann, Meycrsohn. "^ Milhausen. " Ilelnricli. 

"^ Andrejewslcy. ^' Trliainkowsky, Heine. '- Suclis. 

15 Walter (I), Bnlgakof, Guttceit. " Tcliarnliowsky. 


Hungary, fovTning tlio Danubiau basin. The malarial fevers 
prevalent tbrongliout tliis great territory are well known 
under the various names of Dacian, Taurian, Crimean, Wal- 
lacliian, and Hungarian fever, and tlioy have been long of 
evil repute ; even at the present day tliey may be met with 
throughout many of the above-named regions in their old 
pernicious form. A second and less important malarial 
region of Russia extends from Volhynia across the marshy 
level of Western Russia j^ and there arc still other and 
smaller foci of endemic malaria in Tula/ in Jaroslav ^ (sub- 
ject to periodical inundations of the Volga), in Orenburg,"^ 
Samara,^ Kasau,'' at a number of places in the Baltic Pro- 
vinces of Russia, and in the Government of Novgorod where 
lakes and marshes abound.^ The last mentioned may be 
reckoned the most northerly point in Russia to which 
endemic malarial disease extends. Coming to Poland, I 
find more particular accounts of endemic malaria only for the 
Government of Augustowo,^ which has very numerous lakes. 
In Galicia^ also, we find endemic foci of malaria in only a 
few of the smaller districts, especially in the hilly northern 
part of the country, covered with marshes and ponds, the 
department of Cracow, and the circles of Wadowice, Zolkiewo, 
and Zloczow (Brody) ; while the southern part of the country, 
rising in terraces towards the Carpathians, is little affected by 
the disease. A like exemption from malarial disease is enjoyed 
by the southern slopes of the Carpathians. It is when we 
descend into the plain that we come upon one of the largest 
and most notorious malarial regions of Europe, following the 
course of the Danube and its tributaries from the plain of 
Lower Austria, extending on "both sides of the river over a 
great part of Hungary, through the low country of Slavonia 
and Croatia, as well as through the Banat, Syrmia, and the 
Danubian Principalities, and joining on directly, as wo have 
seen, to the great malarial region of Southern Russia. This 
area begins with the great Danubian 'plain of Lower Austria, 
extending from Krems along the river banks to Kornneuburg, 
and thence, widening out considerably and taking the name 

1 Gorski, p. 12. - Koch. ^ gcliolvin. 

■* MaydelL * Ucke, p. 150. '' Erdmann, pp. 150, 250, Blosfeld. 

' Bardowsky. ^ Gorski, p. 11. ■' gcbultes, Scidel, Warscliauer, Weber. 

212 (iKOGrtAriiicAL and historical patuology. 

of Marchfcld, to tlic Ilniigarian frontier.^ There it unites 
with tlio lesser plain of Ilungfiry, a flat country covered with 
lakes and extensive marslies, and equally subject to endemic 
malaria ; on the south it is bounded by the Bakonyan 
Forest, itself the seat of an endemic malaria, while on the 
nearer side it is continued in one direction through the 
counties of Tolna and Barany/ as far as the marshy shores 
of Lake Platen, and in another direction it merges with the 
great 'plain of Hungary. That plain is bounded on the east 
by the metal mountains of Transylvania, on the north by 
the slopes of the Carpathians, and on the west by the 
Danube ; it is traversed by the Theiss and its tributaries 
and covered by extensive swamps, and has long been noted 
for the prevalence of pernicious malarial sickness, the Daciau 
or Punnonian fever of history.^ 

Malaria is widely endemic under the same circumstances 
in the marshy regions of Croatia, in the Danubian plain and 
in the damp valleys of Scrvia and Montenegro,'^ in the Banat, 
and in Syrmia (valley of the Save), whei'C the annual sickness 
in several of the districts most infested by the disease 
appears to reach as high as 30 per cent, of the population, 
while many low-lying places are scarcely habitable ;^ further, 
in the river valleys of Wallachia (especially the Dobrudscha) 
and of Bulgaria, and in the marshy plains and valleys of 
Moldavia.^ In many of the countries here mentioned the 
malarial diseases make themselves felt far up into the 
mountainous districts. 

In the Ballian Peninsula we meet with foci of endemic 
malaria in many parts of Roumelia^ on the shores of the Blade 
Sea and of the 8ea of Marmora,'^ in Albania,^ and upwards 
along the coasts of Balmatia and Istria ; from the latter we 
have more particular accounts of the disease in Badua, the 
marshy plain of Pastrovich, Cattaro, Eagusa, Pola, Citta 
Nuova, marshy spots on the Draga canal and on the Arsa, 

' EbcrstiiUer, Moller. ^ Lncli, Lantz, Eiitz, Scholz. ^ Wutzer, i, p. 319. 

•' Boulogne. '•' Miiller (I), Wouniariiig, Laiubl, AVoinbcrger. 

^ Tchiiriikowslvy, DobrourawoAV, Scidlltz, Witt, p. 45, Barasch, Dumbrcck, 
Scbmalz, Blausteiu, Laudesberg, ClKuupouillou, Lcconto, Obodenaro, Doliio, 

7 Witt, p. 45, Rigler, i, p. 376. 3 Bouaii, Thirk. » Kiglcr, I.e. 


and in Pirano and Capo d'lstria.^ As regards Greece,'^ wo 
are assured of the endemic occurrence of malarial disease at 
many points in Bocotia and (Attica, Levadia, Locris, tlie 
swamp}^ shores of Lake Topolias, Thebes, the country- 
round Athens) Zeituni, Naupantos, and Vonitza (Acarnania 
and Aetolia), at Chalcis in Euboea, in the Peloponese at 
Corinth and neiglibourhood, Vostiza (the ancient Aeg-ion), 
Tripolitza, Mistra, Navarino, Modon, and many other places 
on the coast. In Crete" endemic malaria is very common, 
as it is also in several of the Ionian Islands, particularly 
Ccphalonia, St. Maura and Corfu ;* while Malta enjoys a 
complete immunity from malaria except at a few isolated 
centres near the marsh of Puales, and the frequently 
inundated La Marsa.^ 

Among 83,835 British troops stationed at Malta during tlie years 
1859 to 1875, there were 428 admissions for malarial fever; in several 
of tliosc years there were small epidemics of the fever. 

In the Ajjennine Peninsula^ there are especially two great 
regions that form the seats of endemic malarial disease — 
the Plain of the Pa and its tributaries, and the West Coast 
from Pisa down to and including most of Calabria. The 
first of these begins in the low-lying parts of Piedmont,'' in 
the provinces of Yercelli, Novara, Lomcllina, and Biella, 
and extends thence through the Plains of Lomhardij and 
Venetia,^ following the course of the Po, and of the Ticino, 
Adda, Oglio, Molla, Adigo, and other of its tributaries, 
through the Milanese territory, the neighbourhood of Pavia, 
the country of Siccomario situated between these districts 
and the west of the province of Lomellina, through the flat 

' Verson, Enll, Pacldey, Troghcr, p". 59, B.ixa, Wiener, Jilek. 

^ See Faurc, p. 47 fl", Mott, Olympios, Pallis, Landcrer. 

^ Roseufekl. 

'' Heunen, p. 219, Fcrrara, Black (II), Burnett, TuUy, Davy, ii, cap. 10. 

^ Tully, p. 469, Henncn, 1. c, Iloruor (I), Early, Davy, 1. c. 

^ For a general statement see Corradi, p. 69 ff. Pareto remarks (' Sulle boni- 
ficazioni, risajeed irrigazioni del regno d'ltalia,' Milano, 1865, p. 220), that there 
arc 1,088,961 hectares of marsh land in Italy, of which 65,000 belong to the 
(quondam) States of the Church, 260,000 to the pi-oviuces of Venetia and Milan, 
and a very considerable extent to Neapolitan territory. 

' Maffoni, Fossati. 

s Guislain passim, Valentin, pp. 117, 141, Savio (I), Ferrario, ii, p. 299, Hil- 
denbrand, Menis, i, p. 130, Tassaui, Lippich, Rossi, Agostiui, Donati, Pozzani. 


parts of the provinces of Como, Bergamo and Brescia, Cre- 
mona and district, INIantua, Verona, Padua, and Ferrara, 
and tlieuce across tLo extremely marshy plains that lie 
between the mouths of the Po and the Marecchia (at 
E-imini), among' which the Valli di Comacchio are specially 
notorious for fevers. The second great malarial region of 
Italy, that of the west coast, begins with the marshes on 
both sides of the Arno, near its mouth, extending from 
Pietra Santa downwards by Pisa to Leghorn.^ To the south 
of Volterra and Siena the district merges in the Tuscan 
Maremma, which extends to Civita Vecchia ; this plain, 
bounded on the east by the slopes of the Apeunine, contains 
hardly any marsh, and is for the most part dry and barren, 
but it is notorious for its endemic malaria, which is at its 
worst in the province of Grossetto." At Civita Vecchia, 
itself a hotbed of malarial fever,^ the Maremma merges in 
the Campa(/na di Homa,^ which, together with the city of 
Rome,'' forms one of the chief seats of the disease. 

Next come the Pontine Marshes,^ extending along the foot 
of the hills from Velletri to Terracina, and lastly the malarial 
region on the NcapoUtian West Coast, which includes the 
Terra di Lavoro (with the marshes of evil repute in the 
neighbourhood of Capua), and the provinces of NapoU^ Prin- 
cipato citcriore,^ and Calabria.^ Smaller malarial spots are 
met with also on the Adriatic coast, particularly in the 
neighbourhood of Chieti (Abruzzo citeriore),^*' on the coast of 
Bari,^^ and at several points ou the Gulf of Tarento. Ende- 
mic malaria is widely diffused in Sicily,^" not only on the coast 
or in the plains, but also in the elevated districts. The same 
applies to Corsica/^ especially the east coast, and to Sardinia}* 

1 Valentin, pp. 82, 95, Palloni. 

" Koreff, Marmoecbi, Salvagnoli-Marchctti, Dauesi, Savio (II). ' Jacquot (II). 

'' Valentin, p. 54, Griffith, Folclii, Guislain, .^7 £p, Fourcault, xVrmand (II), 
Colin (I, II), p. 26. 

5 Baglivi, p. 51, Valentin, p. 54, Puecinotti, Uailly, p. i 2;, Folclii, Guislain, 
1. c, Fourcault, Eerard, Jacquot (111), Canicie, Aruiand, Gason, Pallcy (June), 
p. 345, Barndcl, Colin, i, ii, p. 55, Aitken. 

^ Lancisi, Guislain, p. 43, Fourcault, Sotis, Palestra. 

" Dorotea, Do Eenzi, p. 60. 

8 Ely. » Hugi, Manioni. '" Viccntini. " Vitautonio. 

>- Boyle (II), Irvine, p. 3, Ziuinienuann, p. 13. 
'^ Vanucci, Gouraud, p. 29, Abeille, Henuet (III). ^' Moris. 


In Ajaccio tLere arc, amoug- 500 French soldiers, 100 
annual admissions for malarial fever, not reckoning recur- 
rences. In recruiting for the army in Corsica, out of 
1000, representing less tlian half the number of all who were 
liable, 774*73 were found to be unfit for service, and these 
had been rendered unfit for service mostly by severe mala- 
rial illness (Costa). 

For the Iberian reninsula I am able to adduce only a few 
general facts about endemic malaria, owing to the absence 
of more particular accounts. ^ The fevers occur in their 
severest forms, and to the greatest extent, in the southern 
and western coast regions ; in the low country of Andalusia, 
on the marshy banks of rivers, especially the Guadiana and 
Guadalquiver, as well as on the flooded plains of the Tagus, 
Sado, Mondego, and other coast rivers of Portugal, on the 
level coast of Granada and Murcia, and the plains of Algara 
and Alemtejo. Next in frequency, and in less severe forms, it 
occurs on the dry tablelands of Castile and Estremadura (as 
at Madrid and Merida), among the mountains separating 
those two provinces, on the bare coast of Galicia and Asturia, 
as well as in Barcelona, Valencia, and many other towns on 
the east coast. Gibraltar, built on rock, enjoys an almost 
absolute immunity from malarial diseases ; out of a total 
strength of 82,228 men who had been in the British garri- 
son during the period from 1859 to 1875, 657 cases of 
malarial fever were observed, and 145 of these occurred in 
a single year. It remains to mention the Balearic Islands,^ 
especially Majorca, as a region severely infested by malaria. 

On French soil endemic malaria, apart from its prevalence 
at numerous isolated spots.on the damp banks of rivers or in 
deeply-cleft, water-logged mountain valleys, is limited more 
particularly to the western and southern parts of the country. 
The western region of malaria begins in the lower basin of 
the Loire, and extends to the mouth of the Adour, or to 
the foot of the Pyrenees. Upwards from the Loire mouth 
the endemic habitat extends on both sides of the river 
through Nantes,'^ Angers, the arrondisement of La Fleche,* 

1 Proiulfoot (I), Guthrie, Thicry, i, pp. 238, 270, ii, pp. 12, 17, 159, Wilkomm, 
Cuyuat (I), Martinez y Montez, pp. 494, 497, Pacheco, Leitao, Wallace, Brandt. 
-' Weyler. 3 Bonamy, Auizou. ^ Morisseau. 


and DuretaP as far as Tours," tlicnco, tlirougli tlic Sulognc^ 
country to the swampy plain of Brcnnc,^ in the basin of 
the Indre, not less celobratod than the Solognc for the 
deplorable ill health of its inhabitants. The endemic region 
at the mouth of the Loire connects with that of the Vendee,^ 
the marshy soil of Charentc ivfericure^ (including the 
long-known malarial centres {Marnis salantcfi) of La 
Rocholle, Rochcfort, Brouago, St. Agnant, and Marennes), 
the Gironde^ and lastly the plain of Landcs,^ wliere the 
malarial region extends westwards to Norac, and southwards 
to Dax and Bayonno, or to the slopes of the Pyrenees and 
the banks of the Adour. 

The second great malarial region of France stretches along 
the coast of Langitcdoc and Provence, with their numerous 
lakes and marshes. The disease begins to show itself pro- 
minently in Narbonne/ Bezicrs, Cette, Montpellier/^ and 
Nismcs, but the endemic fevers reach their highest point, 
whether as regards extent or severity, in the Rhone delta — 
on Caw.argue,^^ and in the level country on both sides of the 
river mouths (includmg the malarious spots of Aigues- 
Mortes, Martigues, Marignane, and others), and in the Palus 
de Monteux in the department of Vaucluse. Up the Rhone,, 
also, as far as the confluence of the Ardeche, malarial diseases 
are widely spread ;^" and we meet with still another and lai'ger 
centre of them at the confluence of the Saone, in the marshv 
plains well known by their names of Domhes and Brcsse^^ 
which stretch away from Lyons^* between the Saone and the 

' THumeau. 

^ Heyfelder, Charcellay-Lnp^arde. 

^ TessitT, Becquerel, Burdcl, Boullct, Lafont. 

*• Rigodin, Gizot, Bertrand (II), Gaudon, Ilcllaine, Godinat. 

5 Bonte, Moureau, Bouquet, Fleury. 

^ Lucadou, pp. 5, 137, Kctz, Godelicr, Crouigncau, Cornay, Gaillard. 

' Gintrac, Burquet, Lc Gendre. 

' Dufau, Mondineau, Faye, Sorbets, Lavicllo. 

3 Cafford. 

10 Bartlicz. 

11 Bourely, Boillan-Casteluau, Soumcirc. 
i» Madier. 

" Nepple, Vouarin, Rollet, Bcangrand, Boux, Magnin. 

'^ Marmy et Quesuois^ pp. 1 20, 185, 554. Account in the ' Comptes rend, dc la 
Soc. de Med. de Lyon,' 1840, p. 1 13. 


Aiu ; and from these we may follow endemic malaria info 
the country lying between the Saone and the slopes of tho 
Jura as far as Auxonne. Of smaller malarial centres on 
French soil, there deserve to be mentioned the richly 
watered plain in Auvergne extending between the mountain 
ranges of Cantal and Forez, and well known by the name o£ 
Limagne^ and tho marsh conntry around LaJce Indro," in the 
department of Meurtho. 

In Sivifzcrland, where there were formerly many small 
spots of endemic malaria in damp river valleys (of the Rhino,, 
Linth, Eeuss, &c.), and on the shores of lakes (especially tho- 
lakes of Zurich and Lucerne) tho disease occurs now cnde- 
mically at only two points, in the southern part of the Canton, 
Ticino and in the Canton Vallais along the Rhone, especially 
from Sion to its inflow into the Lake of Geneva.^ 

In tho south-Avestern parts of Germany we meet with 
small and narrowly circumscribed foci of the disease on the- 
marshy banks of rivers or lakes and in damp mountain 
valleys (as in the side valleys of the Neckar in the Black 
Forest) •,'^ but, besides these, there are larger malarial 
regions on the hanJcs of the Rhine (in Lower Alsace)," in tho 
Palatinate,^ and the Rheingau,^ and in the low grounds of the 
Danube and its side valleys in Wiirtcmborg^ and Bavaria.* 
In Atistria it is again along tho Danube that we find the 
chief seats of endemic malarial disease, although there arc 
also smaller malarious spots in the river valleys of Upper 
Austria,^° Salzburg,^^ Styria,'" and Carinthia ;^^ where the river 
widens out at Krems, we come upon that great region of 
disease which extends, as we have seen, along its shores to 

' Monfalcon, Ninet et Aguillion. - 
- Assalon, Lefcvrc. 
^ Lombard. 

'' Roscli(I), Leube, Ludwig. 

^ Renaudin, Cuynat (II), Habn, Stoeber et Tourdcs, p. 403, Wasscrfuhr. 
^ Pauli, p. 163, account in the 'Bayr iirztl. Intelligonzbl.,' 1854, p. 426. 
^ V. Fianquc, Lanz, Bliimlein, in the ' Vierteljuhrschrift i'iir gerichtl. Med./ 
1878, xxviii, p. 100 ff. 
8 Majer (I), Volz. 
^ Schroder. 
"> Streinz (I). 

11 Ozlberger (I, II). 

12 Waser, Onderka, Weiglein, MacLer. 
'3 Ilussa. 


the Black Sea. In Central Germany, tlic disease as au 
endemic is coufiued to a few small districts. In the plain of 
NortJi Germany, on tlio otlici* liand, it is much more widely 
spread, being found in the basins of the Vistula, Oder, Elbe, 
Weser, and Rhine. The prevalence of malarial diseases 
is not inconsiderable even in the delta of the Vistula, in 
Lower Silesia,^ and at a few places in the Marie of Branden- 
burg and in Mccldenhimj ;" but it reaches its maximum, 
both of extent and severity, in the western coast districts of 
Ilolstein and Scldesivuf (especially Dittmarsh), on the coast 
belt west of the Elbe, the moor lands of Hanover^ and Olden- 
Ijurg,^ the damp and in part Avater-logged low grounds of 
Westphalia,^ and in the plains oillhenisU FrussiiiJ bordering 
the Rhine and its tributaries. 

This malarious region of the plain of Germany is con- 
tiued without break across the Netherlands^ frontier, where 
the disease is mostly found in the provinces of Gronland, 
Eriesland, and Zeeland with their brackish marshes (the so- 
called " poklers ^'), and in the coast belt of the provinces of 
North and South Holland ; it is endemic also in the pro- 
vinces of Drenthe and Overyssel, and in fact no province of 
Holland is altogether free from it. This malarial area on 
the west coast of the country merges in the endemic fever 
region of the low-lying parts of Belgium, particularly West 
Flanders with its numerous marshes, and also East Flanders 
and Antwerp -^ whereas the elevated and dry provinces of 
Brabant,^" Namur,^^ Liege and the like, are little affected by 
malaria, and the mountain districts proper are quite free 
from it. 

^ Lorinser, Klose, Graetzer. 

- Helm, Bruckner, Accounts in ' Beltr. Mecklcub. Acrztc,' pt. i, p. i, pt. ii, 

pp. 1, 19- 

•* Hannaeus, Liidcrs, Friedlieb, Dohru (I), Dose. 

•^ Lauts, Gittennann, Toiil, Miqucl. ^ Goldsclimidt, Wcnzel. 

« Driifel, Nicolai, ' SanitJitsbericlit von Wcstfalon f. d. Jalir 1838,' p. 86. 

' Steiffensand, p. 145 ff. 

5* Sebastian, Thijssen (I), llombach (I), Nieuwcnhnys, v. (Scuns, Ucport in 
' Algemeene Statistick van Ncderlaiid,' Leydeii, 1S71, ii, p. 159 ff, Deduin. 

3 (iouzee (I), Moynnc, 270 iV, Jaiissens, Keuwer, Pattyn, Wocts, Vrancken, 
Waldack, Luyx, Pujtcrmaus, Tliijs, Titeca. 

'" Severon. 

" Sovct. 


The British Islands eujoy a very notable immunity from 
endemic malarial disease, particularly IrcliDuJ} and Scotlioul" 
(wliicli is now at least quite free from it), and the northern 
counties of England? and Wales. The only localities in which 
the disease is endemic to any considerable extent occur 
on the east coast,^ including the East Riding of Yorlcshire, 
the counties around the Wash noted for their Fens (Lincoln, 
Huntingdon, Cambridge, and Norfolk), where, however, the 
fever has lately decreased to a great extent,^ and the 
counties of Essex and KoitJ^ In the rest of England we 
meet with only isolated and narrowly circumscribed spots of 
malaria, mostly associated with damp or water-logged river 
banks, as on the banks of the Thames in Surrey,^ and in the 
South Marsh of Somersetshire.^ 

In the islands of the kingdom of DenmarJc, where malarial 
fever was formerly reckoned among the prevalent diseases, 
it now occurs as an endemic sickness only on the islands of 
Laaland and Falster.^ It is still meet with in Norivay as an 
endemic on the Hvaloer islands (at the entrance of the 
Christiauia Fjord), and in the neighbourhood of Frederikstad.^° 
In Sweden the foci of malaria appear to have increased con- 
siderably in extent and in number of recent years. The 
disease is found as an endemic at three principal points :^^ in 
the central depression of the country around the shores of 
the great lakes, especially Lake Miliar and Lake Wener, the 
most northern limit of its diffusion there being the 
Hedemora district (Fahlu-Lan) in G0° 20 N. ;^^ on the east 
coast of Torhamn near Hudiksvall (G2° N.), being most 
developed in Kalmar-Lan ; and at the mouths of several 
coast streams such as the Angermanna-Elf, the Dal-Elf, and 
the Gotha-Elf. Malarial fever is not endemic in Finland, 

1 Wylde. * Cbristisou. 3 Proudtbot (II). 

■* RoystoD, Watsou (I). ^ Grautham. 

^ ' Report of the Med. Officer of the Privy Couucll,' 1859, p. 35. 
7 Hicks. [The Essex shore of the Thames (Barking, Grays), is still a seat of 
iuahiria ; Surrey and Kent have ceased to be so in any especial sense]. 
^ Peebles, Symonds. 

9 Otto, Bremer, ' SundhetscoU. Aarsberetning for 1876.' 
i» Kjerulf, Broch. 
'^ Bergmann, p. 139. 
" Hallin, Hjelt, Estlander. 


nor has it been observed in tlie Faroe Islands^ or in Iceland' 
apart from imported cases. 

In the Weste7-n UemispJicre endemic malarial fever of the 
severest type has its principal seats in the West Indies, on 
the Mexican Gulf coast, and in Brazil ; but considerable 
regions of fovcr, though of a less intense kind, are met with 
in the northern parts of the Pacific coast of South America, 
and in the southern, central, and prairie States of the Union. 

West Indies. — Among the West India Islands^ those 
chiefly affected by malarial sickness are Cuba,"* Jamaica,'' 
San Domingo,^' Guadaloupc,^ Dominica,^ Martinique,^ Sta. 
Lucia,'° Grenada,^^ Tobago and Trinidad^" ; while others, such 
as Antigua, St, Vincent,^^ and Barbadocs^* enjoy a relative 
immunity, and the last of these is even in high repute as a 
sanatorium for patients with malarial sickness. In the 
Bahama^'' malarial fever is comparatively rare ; in the Ber- 
muda group it is almost unknown.^*^ 

In the Baliamas, from 1S67 to 1873, there were 305 cases of malarial 
fever among 1676 black troops stationed there (or 19 per cent.); 
whereas in Bermuda, from 1859 to 1S75, 48 cases of malarial fever were 
observed among 24,941 European troops (or o"2 per cent.), and most of 
these did not originat,e there, but in the West Indies. 

South America. — One of the worst centres of malaria is 
on the East Coast of South America, including the very un- 

^ Manieus, Panum. 

* ScLleisner, p. 2, Finson. 

2 For general information sec Cliisholm (I), p. 32 ff. 

* Sullivan. 

^ Sloane, p. 14, Hunter (II), p. 57, Jackson (HI), Arnolil. 

^ Desportcs (I), pp. 52, 93, kc. 

^ Datroulau, p. 30, Pellarin (II), Manceaux, Carpcntin, Batty-Bcrquin, Rai- 
mond, Napias. 

8 Imray. 

5 Savaresy, pp. t,t„ 51, Dutroulau, p. 30, Saint Vol, Pellarin (I), Rufz» 

1" Wright (II), Evans (II), Levaelier, p. n i. 

11 Chisholm (II). 

12 McCabe. 

" Hunter (III). 
^* Schomburgk, Jackson (IV). 
15 Cleveland. 

1^ Account in the ' Sanitary Report on the Colony of Bermuda for 1872,* 
Hamilton, 1872. 


healthy ports of Carthagena, Maracaybo, and Puerto Cabello, 
uud the ill-reputed country of Guiana^ where the fever is a 
terrible scourge to the inhabitants, not only on the coast, 
but also, and even still more, on the inland plains and in 
elevated situations. 

Of 33,486 patients admitted during ten years into the hospital at 
Cayenne, 16,451, or 50 per cent., were sufFcring from malarial diseases, 
and in one year (1855) 13,423 kilogrammes of quinine wei-c used at St. 
Marie de la Comte, among a force of about 650 men effective (Chevalier). 
In British Guiana, the number of admissions for malarial fever among 
the gai-rison (as averaged for the period from 1859 to 1863) was 77 per 
cent, of the total strength ; according to Blair's account, quinine is 
used there to the amount of 20 gi-ains annually per head of the popu- 

A region of less intense, but very widely spread malaria, 
covers almost the whole of the north of Brazil^ as far down 
as Rio de Janeiro ; and here also the disease is equally pre- 
valent in coast localities and elsewhere — on the flat and often 
inundated banks of the Amazon, Rio Madeira, Maranhao, 
Paranahyba, San Fi'ancisco, Parana, Rio Doce and their tribu- 
taries, on the island of Santa Catarina, and in the marshy 
districts (some of them elevated) of the provinces of Piauhy, 
Para, Mato Grosso, Goyaz and Minos Geracs. There are 
also widely diffused endemic foci of malaria in the prairie 
lands (pampas) of Paraguay^ and Bolivia,^ particularly in 
the provinces of Tucumaua, Salta and Santa Cruz. The 
circumstances are decidedly more favorable in the southern 
provinces of Brazil, San Paulo and Rio Grande do Sul, and 
that applies still more to Uruguay and the eastern provinces 
of the Argentine Bepuhlic, which, according to the unanimous 
verdict of observers, enjoy an almost absolute immunity 
from malaria.'^ On the Pacific coast of South America, 

' Biijon (II), p. 20, Campet, p. 81, Segond, Lauve (I), p. 7, Dutroulau, pp. 18, 
250, Lauzacli, Chevalier, Maurel (for Cayenne), Schollcr, Ilillc, Po^jp (for 
Surinam), Roclclisied, p. 215, Blair (for Brit. Guiana). 

* Sigaud, pp. 157, 216, Lallemant, Gardner, Rendu, p. 67, St. Hilaire (II), 
p. 50, JoLiiu, Plaggc, account in ' Gaz. med. da Baliia,' 1868, May, p. 15, Bourel- 
IJonciere, Rey (II). 

^ Mantegazza (I), p. 286, (II) pp. 8c, 224, Mastermau. 
■» Bacli. 

* Dupont, p. 13, Brunei, p. 36, Manlcgnzza (I), p. 100, Feris (II), 


Chili, which was formerly quite exempt from malaria/ has 

been visited since 1851 by pernicious epidemics, and at a 

few points in that country the disease has assumed an endemic 

character ;^ but the proper region of severe endemic malaria 

does not begin before Peru, where the disease occurs very 

abundantly and in severe forms equally on the coast and 

among the deep eastern valleys and spurs of the Sierras.' 

The endemic sickness extends thence along the coast to 

Ecuador,^ and probably also to New Granada ; in the eastern 

parts of Ecuador, especially in the districts within the upper 

basin of the Maroiionj malarial diseases are said to be rare.'' 

Central America. — In the countries of Central America,^ 

the malarial diseases have their chief seat on the Atlantic 

(Gulf) coast from Chagi-es up to Capo Garcias a Dies, and 

on the interior plain up to a height of 600 metres. The 

Pacific coast is loss severely visited, although there also 

endemic foci of malaria are met with, particularly in Corinto 

(port of Nicaragua)/ on tbe coast of San Salvador and in 

the valleys of the Lempa and St. Miguel/ as well as on the 

coast of Guatemala.'' In Mexico, also, it is on the Atlantic 

coast that malaria predominates, as in several ports of 

Yucatan (Belize in British Honduras,^" Sisal and Carmen), 

on the coast of Tabasco,^^ in Alvarado, Sacrificios, San Juan 

d'Ulloa, Vera Cruz,^^ Tampico and Matamoros (Tamaulipas), 

along the banks of the Bio Grande del Norto/^ and elsewhere.^* 

It is met with also as an endemic, althougli on the whole less 

frequently, at many points in the Sierra Templada as high as 

1200 to 1500 metres (as in Orizaba^^ and Oaxaca^^) ; it is only 

on the table-land proper (Anahuac) that it vanishes entirely, 

1 Laf argue, v. Bibra (I), Eojd. ^ Pidcrit, Le Roy (III). 

3 Hamilton (I), Tschndi, Le Roy (II), pp. j8o, 188, Fournier. 
•» Le Roy (II), p. 280. s Gait. 

" For the Istbinus of Panama : Lidell, Buel, Le Roy (II), p. 285, Wagner (II), 
p. 20, and Schwalbc ; for Costa Rica: Le Roy (II), p. 373, v. Frantzius, and 
Scbwalbe; for Nicaragua: Bernbard, Le Roy, p. 376, Watson (II) j for tbc 
Mosquito Coast : Young (III). 

'• Gibbs. ** Guzman. ' Durant, Bernouilli. 

"' Hamilton (II). Of 4045 Britisb troops (bliick) looS, or 75 per cent., 
sickened of malarial fevers during tbe years 1859 *" '873. 
" Morel, Heller, Miiller (II), Joxirdanct, p. 150. 

'- Napbegyi, Hclnemann (II). Yaillant and Coirc do not admit tbc endemic 
prevalence of malarial fevers in Ycra Cruz. '^ Pouilk', Pirion. 

" Dcbout, Pommicr, p. 37. '^ Tbomas (I). ""' Uslar, Ikiremann (I). 



SO that nt tlic elevation of the city of Mexico malarial fever 
is observed only as an epidemic now and then.^ 

On the raci'fic coast of Mexico the circumstances as regards 
endemic malaria are the same as for the adjoining coast of 
Central America ; here also the endemic fevers arc confined 
to a few points, among which may he mentioned Acapulco, 
Tepic, and the strip of coast from San Bias to Mazatlan." 

United States. — Beyond the Rio del Norte, this great 
malarial region extends over the whole GuJf const of the 
United States as far as the Capo of Florida, spreading far 
into the interior of the continent along the Colorado, Brazos, 
and Mississippi, and their tributaries.^ In Texas'^ the malarial 
region stretches from the coast and the swampy banks of the 
Rio del Norte, Nueces, Colorado, and the smaller coast 
streams up into the highlands, where foci of severe sickness 
are met with as high as the upper basin of the Colorado 
(Fort Duncan in Eagle Pass), and at Fort McKavit at a 
height of 600 metres. The disease appears to be still more 
widely diffused in Neiv Mexico, being met with at elevations 
of over 20G0 metres in Fort Bayard, Fort Union, and other 
places, and forming a terrible scourge to such of the native 
population of the country as inhabit the damp valleys. The 
limit of its endemic prevalence hero is Santa Fe (2300 
metres), where malarial fever is no longer met with.^ From 
the western part of the Louisiana coast,^ between the Sabine 
and Mississippi, the malarial region extends across the zone 
of bluffs in that State, over a great part of Arlmnsas, 
particularly along the banks of the Mississippi and Arkansas 
rivers, and over the marshy plains in the north-east of the 
country, stretching away towards Missouri, and still farther 
along the Arkansas river over the eastern part of the Indian 
territory, including the malarious spots of Fort Gibson^ 
(noted as the ''' charnel-house of the army)," and Fort Sill. 

^ Newton, Jourdanct, p. 387, Liberman. 

- Celle, p. 26, Caddy, Girard, pp. 13, 18. 

3 See particularlj Bartlett, p. 345, Drake, and the ' Statistical Reports on the 
Sickness and Mortality in tlie Army of the United States' (in synopsis of the 
literature, ' Reports ' II). 

^ Meyer, Brachl, Neufville, Moses (I), Rosch (II}. 

5 See 'Reports' (II), i860, pp. 213, 218, 223. « Collins, Gibbs. 

^ Wright (III), Coolidge, Sinks (on the endemic malaria of Kansas). 


Malarial disease is endemic al ouly a few scattei'ed poiuls 
in the great prairie laud of this territory, wliicli rises towards 
the Rocky Mountaius from south-east to north-west, and has 
a dry sandy soil, not often saturated by any heavy falls of 
rain. In like manner, the eastern part of Louisiana, beyond 
the Mississippi, forms part of a region little subject to 
malaria ; this region includes the coasts and the hilly zone 
of the State of il/mm-y*2'*V ^^^ ^^ particular the Pine Woods, 
so much reputed for their healthiness, a range of moderately 
high sand-dunes, covered with fir woods, which begin at 
Lake Pontchartrain and run along the coast at no great 
distance inland, as far as the Bay of Pensacola, intersected 
by the Pearl River and by the Pascagoula, Perdido, and 
Alabama. These Pine Woods aro much resorted to by the 
inhabitants of New Orleans and Mobile when malarial fevers 
and yellow fever are prevalent. On the belt of hills in 
Mississippi State, as far as Vicksburg, malarial endemics are 
met with at isolated points ouly, as for instance, on Grand 
■Gulf, wdiich is notorious for its fever; but from Vicksburg 
there spreads out along the valley of the Yazoo a great 
swampy plain rising towards Memphis, noted for the endemic 
prevalence of severe malaria ("Yazoo swamp fever"). The 
eastern hill region of Mississippi is well situated as regards 
healthiness, and that is the case also with the greater part of 
the sparsely populated State of AIahama",m which malaria is 
endemic chiefly on the coast, especially around the swamps 
on the Bay of Mobile, on the banks of the Alabama aud 
Black Warrior (counties of Wilcox, Dallas, Lowndes, Mont- 
gomery, and Tuscaloosa), and on the marshy plain of Hunts- 
ville, lying to the south of Tennessee and reaching to the 
borders of that State. In the Peninsula of Florida,"^ the 
sickness is widely diifused on the Gulf Coast with its jungles 
and swamps, particularly in the counties of Escambia (includ- 
ing Pensacola) and Gadsden, at Tampa Bay, Fort Meade, 
aud other places; the same is true also for part of the Atlantic 
coast,* but in a lesser degree ; for the health there, especially 

^ Wharton, Fcrrar, Montgomery. 

^ Lucas, lleustis (I), IJoling, Lcvandcr, Hates, Wooten, Capsliew. 
3 Porter (1), Little, Gaillard (I), 'Reports' (II), 1856, pp. 309, 33G. 
' 'Reports' (11), i860, pp. 148, i5i, 164. 


in St. Angustino, appears to have improved materially in 
recent years. But the chief scat of malaria in this State is 
formed by the plains of the interior, partly swamp, and also 
by the plateau of no great elevation which forms the water- 
shed for the Bay of Tampa, and rans up the peninsula to 
Georgia. In Georgia the disease prevails widely and in 
severe forms/ not only in the numerous creeks of the coast, 
but also in the interior, the neglect of agriculture in quite 
recent times having greatly conduced, as it seems, to an 
increase both in the amount and intensity of the endemic fever. 

In the Central States of the Union, malaria is endemic 
to an extent that is still considerable, though materially 
less than in the Southern States ; and chiefly on the coasts 
of South Carolina^ North Carolina^ Virginia,^ and Mary- 
land,^ and on the damp river banks of the interior. Im- 
provement of the soil has helped not a little to narrow the 
range of the endemic in these States ; but it is rather 
remarkable that malarial fevers have increased within the 
last twenty years in localities formerly little touched by them, 
especially in the mountainous districts of Virginia.'' In the 
inland Central States of Tennessee^ and Kentucky ,^ malarial 
fever occurs to a moderate extent along the banks of the 
Mississippi and Ohio, attaining its greatest prevalence on the 
prairies of the latter State known as " the barrens.^' On 
the prairie States proper,^ Ohio, Indiana, Illinois, Missouri, 
Iowa, Minnesota, Wisconsin, and Michigan, malarial fevers 
arc likewise widely prevalent, diminishing in frequency, 
however, towards the north west. Thus, in the northern 
parts of Iowa the fever is no longer so common as in lower 

^ Le Conte, DunioU (I), Pendelton, Posey, ' Report of the Board of Health of 
the State of Georgia/ Atlanta, 1876. 

3 Simons, Collins, GaiUard (II), Porter (II). 

3 Williamson (II), Norcom (I), Norcom (II), McKee, Mansou, Dickson, Win- 

* Somervail, Thomson (II), Perkins. It is stated by Bland that Virginia 
west of the Alleghanies is quite free from the disease, except at a few endemic 
malarious spots on the banks of the Ohio. 

5 Beatty, Stille, Reyburn. 

" Simons, McKee, Perkins. 

^ Ramsay, Bectou, Higgason, Buchanan, Hogg, Harper, Cunningham, Tuck 
Grant, Bailey. 

s Yandell. 

" Bradford, Parry, Carrol, Hewins, Cook Farnsworth. 




latitudes under the same circumstances of tillage ; and 
that is the case also in Wisconsin and Minnesota, where 
the rate of malarial sickness among the troops (in Fort 
Snclling, 42-52° N., and in Fort Eiplcy, 46-10° N., hotli on 
the Mississippi) amounts to about 1 5 per cent, only ; still more 
is it the case in the territories of Dakota and Montana, 
where the rate falls respectively to 5 per cent, and 6 per 
cent. The largest foci of disease in those regions are met 
with on the shores of the great lakes ; and here, again, 
the geographical situation proves to have the most decided 
influence on the occurrence of malarial sickness. Thus, the 
shores of Lake Superior, and in part, also, those of Lake 
Michigan and Lake Huron, are entirely free from fever ; it 
is not endemic, for example, at Winnebago, Wise, in latitude 
44° N., notwithstanding marshes and a damp river bank, 
and it is comparatively rare in the swampy settlement of 
Fort Brady.^ It is in the southern parts of the State of 
Michigan" that we come upon the true domain of malaria, 
and we then follow it along both shores of Lake St. Clair 
to the junction with Lake Huron, and along the southern 
shores of Lake Erie and Lake Ontario as far as the St. Law- 
rence. Detailed accounts from that region speak of perni- 
cious malarial fevers at Fort Gratiot, Detroit, Plymouth, and 
other places on the United States side, and at Amherstbury, 
Fort Maiden, Sandwich,^ &c., on the Canadian side. Even 
on the northern side the range of sickness on Lake Ontario 
extends from Hamilton to Kingston, and still farther up 
the ridge which runs along the shore from Burlington to the 
mouth of the Trent, attaining in some places a height of 
more than 600 feet.* 

These lake-shore endemics of fever extend also to the 
north-western parts of the State of New Yor/r, although there 
are many localities in the counties of Onondega, Tompkins, 
Seneca, Ontario, Oneida, and others, formerly much subject 
to fever, that have now become tolerably free from it owing 
to improvements in the soil.'' It is mostly along the banks 

1 Reports (II). ^ Sutphen, Beech. ^ Poucet. 

* Mendenhall, Drake, i, p. 334, 'Reports' (II), 1859, p. .0, Spraiiuc, Stratton, 

* Fribre, Brown (II), Hart, Smith (III). 


of the Hudson, and on a narrow strip of the coast, that 
the sickness is endemic in this State ; but within the last 
twenty or thirty years a remarkable increase of fever has 
been noted in the counties situated among the mountains.^ 
The same thing has been observed also in Pennsylvania ; as 
the disease has retired from places that used to be its head- 
quarters, such as the country bordering the Schuylkill, the 
Susquehanna, and the Delaware, it has come to be more pro- 
minent in the mountainous districts of the State.^ It must 
remain au open question how far improvements in the soil 
have contributed to this decrease of malaria in its old foci ; 
at the same timo it is undoubted that it has been observed 
to disappear from localities where no changes in tho ground 
have taken place. The latter circumstance obtains, in part 
at least, for New Jersey also, where there has been a remark- 
able decrease of malarial fevers within recent years in many 
localities that used to be visited by it severely." 

In the New England States malarial fever is endemic at 
only a few points 3* in tho State of Maine it is no longer 

Neither is it endemic througliout the greater part of 
British North America. For Canada, as well as for the 
whole inland basin of the continent, Kingston (44"8° N.) is 
the northern limit of endemic malaria ; as an epidemic, one 
meets it at higher latitudes, on the banks of tho St. Law- 
rence and its tributaries, on Lake St, Peter, very rarely at 
Montreal or Quebec, or places on the coast such as Halifax^ 
(N. S.) and Miquelon (N. F.) in the latitude of 46*30° N. 
The cases in Nova Scotia and New Brunswich are imported 
ones. In. Greenland malarial fever is quite unknown,^ 

In the western regions of North America the limit of 

J Sraitli (III), Trask, ' Reports ' (II), 1840, pp. 130, 133, 1856, p. 14. 

^ Rush, p. 97, Parrish, Accounts in the ' Transact, of the Pennsylv. State Med. 
Soc.,' 1862, 1865, 1867, 1868. 

3 Accounts in the ' Transact, of the New Jersey State Med. Soc.,' 186 1, 1862, 

^ 'Reports' (II), 1840, pp. no, 114, 117, 121, 125, 1856, p. 9, i860, p. ro, 
Threiidwell (for Boston), Sec p. 232, 

^ Wotherspoon, 'Reports' (II), 1840, pp. [42, 146, 1856, pp. 27,30. 

" Boyle (III), 

7 Lange, p, 32, 

228 GEOGUArniCAL and historical rvTiroLOGY. 

malaria readies to somewliat higher latitudes. It is preva- 
lent there chiefly on the slopes and in the valleys of the 
Rocky Mountains' — whence the name of " mountain fever " — 
in the territories of Wyooning, Utah/ and Golurado, and it is 
especially disastrous to the Indian tribes.^ Only imported 
cases occur at Fort Vancouver {Washington Territory^ in 
latitude 45*40° N., and on the Oregon coast/ as well as in 
Alaslia^ (formerly belonging to Russia). Not until Cali- 
fornia} do we reach a more considerable malarial region on 
the west coast ; it extends up the valleys of the Sacramento 
and San Joaquin ; aud in the inland southern part of the 
State (Arizona) malarial fevers appear to be widely preva- 
lent. But the sub-tropical coast of Southern California from 
Monterey to San Diego enjoys a noteworthy immunity from 
the sicknesS;^ being iu that respect similarly situated w^th 
the Pacific coast of Mexico aud Central America. 

§ 61. Epidemics and Pandemics — Old Seats and New — 

New Types. 

The area of distiMl)utiou of malarial disease hero sketched 
in general outlines will have to be considerably extended if 
we take into account not merely the endemic occurrence of the 
sickness^ as we have hitherto done, but also those regions in 
which the disease a])pears only now and then as an epidemic. 
These epidemics of malaria, which extend not unfrequently 
over large tracts of country, and sometimes even over whole 
divisions of the globe forming true ■pandemics, correspond 
always in time with a considerable increase in the amount of 

' Smart (II). 

^ Ewing, Bartholow, Waggoner, Brewer. 

•'' Wilkes (IV), p. 369, Gairdncr, Moses. 

* Maurin. 

■^ Glisan. 

" Blaschke, p. 62 ; during a five years' residence at New Archangel he saw 
only three cases of rualarial fever. 

7 Stillman, Blake, Hammond, Praslow, p. 44, Gibbous, Logan, Keency (in 
' Reports ' (II), i860, p. 243.) 

^ King, Summers (in 'Reports' (II), i8i;6, p. 438), Biggs and Graves (in 
' Tranpact. of the Californ. Slate j^Ied. Soc.' for 1S70 and 1871). According to 
the account of HofTmann (ib.) malarial sickness is endemic iu Sau Diego itself. 


sickness at the eudemic malarious foci, wlietlicr near or 
distant ; they either die out after lasting a few months, or 
they continue — and this applies particularly to the great 
pandemic outbreaks — for several years, Avith regular fluctua- 
tions depending on seasonal influences. 

yy'On the very verge of the period to which the history of 
malarial epidemics can be traced back, we meet with a 
pandemic of that sort in the years 1557 and 1558, which is 
said to have overrun all Europe.^ It is impossible to decide 
from the scanty and incomplete epidemiological data of the 
sixteenth and seventeenth centuries how often such epidemic 
outbreaks of malarial fever may have recuiTed in times sub- 
sequent to that pandemic; it is not until the years 1678- 
1682 that we again meet with definite facts relating to an 
epidemic extending over a great part of Europe ; and there- 
after follow at short intervals reports of the same kind for 
the yeai's 17 18- 1722, 1748- 1750, 1770- 1772, and for a more 
restricted epidemic in 1779- 1783. Although malarial fever 
during the last ten years of the previous century and the 
first five years of the present had absolutely disappeared 
from the arena of national pestilences, and had even 
diminished considerably in those places where it was 
endemic, there developed in 1806 a pandemic of malaria 
which overran a large part of the north and north-east of 
Europe, lasting till 181 2; it coincided with an epidemic of 
malaria in Southern India in 1809-181 1, which extended from 
the slopes of the Mysore mountains to Cape Comorin, and 
from the Western Ghats to the Coromandel coast. During 
the ten years following, malarial fever was again confined 
within its habitual limits ; but thereafter, a little earlier or a 
little later in the several regions, there arose one of the most 
extensive, severe, and persistent of pandemics, beginning in 
1823 and dying out in 1827, of which there are numerous 
medical reports from almost all parts of the world. The 
next general epidemic prevalence of malarial fever falls in 
the years 1845- 1849, after which comes the great pandemic 
of 1 855- 1 860. Finally, we have the malarial pestilence of 
1 866- 1 872, in which the disease spread not only over a great 
part of Europe, but visited simultaneously many parts of 
^ Palmarius, ' De morbis contagiosis,' lib. vii, Paris, 1578, p. 322. 


India (Presidency of Madras, Lower Bengal, Punjaub, &c.) 
and of North America, and showed itself for the first time, 
and that too in a severe form, in the islands of Mauritius and 

Decrease or disa2y2^earancc. — To complete this account of 
the historical and geographical aspects of malarial disease, 
we must first of all observe that in many parts of Europe 
and North America it has become of recent years not only 
less frequent than in the previous century, but also less 
severe in type. Pernicious malarial fever was prevalent as 
late as the eighteenth century in many parts of Germany, in 
the Harz, in Augsburg, Saxony, Silesia, Wiirtemberg, and 
other localities where now it occurs only in occasional 
epidemics, and then always in its mildest forms. At the 
time of Sydenham and Willis and of Huxham, London and 
Plymouth were dangerous fever spots, whereas to-day 
malaria is a rare thing in them ; and the same applies to 
Stourport,^ Bolton," and other towns in England. In Scot- 
land, where there were still many endemic malarial foci 
remaining in the eighteenth century,^ the disease is now 
extremely rare. It is the same in Ireland, where, as Wylde 
remarks,'^ no acute infective disease is so rarely met with as 
malarial fever. It is further noteworthy that the disease has 
become less common and milder in character in the Nether- 
lands, in many parts of Belgium,^ and at numerous points in 
the United States of America, particularly in certain counties 
of Pennsylvania,^ New York, New Jersey^ and Maryland,^ that 
used to be much subject to fever; in some of the Southern 
States also, such as Florida,^ the disease has assumed a 
decidedly milder form. 

Fluctuations. — Not less striking than this gradual sub- 

1 Watson (III). 2 Black (I). 

3 Christison. Wilsou (II) observes that, whereas in the ten years from 1777 
to 1787 the annual number of malarial cases iu Kelso was one seventh, and 
sometimes even one liith of the total sickness, it had fallen in the ten years 
from 1829 to 1839 to one six-hundredth. 

^ 'Edin. Med. and Surg. Journ./ Ixiii, p. 263. 

'•" Meynnc, p. 284. 

" ' Trans, of the State Med. Soc. of Pennsylvania,' 1856-60-62-65-67-68-71-72. 

7 ' Transact, of the State Med. Soc. of New Jersey,' i86i-62.68. 

8 Worth. 

3 Galllard (I). 


sidence and disappearance of the disease are tlie fluctuations 
observed, at the several places, in the amount of the sick- 
ness, partly connected no doubt with the already-mentioned 
pandemic outbreaks of malaria, but to some extent inde- 
pendent of these. Another noteworthy circumstance is the 
development of endemic foci of malaria at places that had 
been hitherto quite exempt, or only occasionally visited by 

Thus, to mention only a few of the facts : a widespread outbreak of 
malarial fever appeared in 1823 at Prague, where the disease had not 
been known for years; it continued until 1830, when it again became 
very rare, and it did not receive any considerable fresh accession until 
1846.' At Stuttgart, where malarial fevers are counted among the dis- 
eases most rarely observed, the sickness, after being epidemic in 1826 
and having been completely extinguished, broke out still more exten- 
sively in 1834,^ and showed itself in the very same year at other places 
in Wiirtemberg occupying elevated and dry situations. At Konigsberg 
(Province of Prussia), where the conditions of the soil are very favorable 
to malaria, the sickness was scarcely observed at all from 181 1 to 1825, 
but after that an epidemic of it develoj)ed which lasted until 1833 ; from 
1833 to 1841 the disease recurred in isolated cases only ; from 1841 to 1852 
it appeared every year in the spring to a moderate extent, but from 1852 
to 1855 it was prevalent to an extent and of a severity that one but 
rarely sees in so high a latitude? Observations to the same or corre- 
sponding effect have been made at Marienwerder,"* Leipzig,* Erlangen*^ 
and other places in Eiu'ope ; also at the more intense centres of malaria, 
as many facts from tropical countries prove.'' 

Neiv Foci. — A phenomenon not less interesting meets us 
in the fact often observed in more recent times, of new foci 
of malaria being established, or of its epidemic continuance 
for several years, and its wide diffusion, in localities which 
had previously been quite free from it, or at least practically 
free from it. 

One of the islands of the Indian Archipelago, Amboina, had, until 
the year 1835, enjoyed a remarkable immunity from malarial sickness; 
but in that year a severe epidemic arose, it is said in consequence of an 
earthquake that took place at the time, and since then the island has 
been a permanent seat of pernicious malarial fever, and has conse- 

1 Biscboff (I), p. 31. 2 ciesg (ii). ^ Hirsch. 

^ Heidenhain. * Thomas (II). ® Kiittlinger. 

7 In the Presidency of Madras, the number of deaths from malarial disease 
from 1868 toi87i rose from 105,692 to 132,346, 151,027, and 193,398, or almost to 
double within four years (' Madras Monthly Journ. of Med. Sc.,' 1872, v, p. 298). 


quently become one of the most uiihe;iltliy places in the East Indies. 
The East African islands of Mauritius and Reunion expeinenced the 
same fate in iS66; they had i^reviously been almost exempt from 
malarial fever, but in that year a disastrous malarial epidemic deve- 
loped, and its persistence to the present time makes it probable that 
endemic foci of the disease have been established.' In Chili, where 
malarial fever was formerly almost unknown, the disease showed itself 
first in 1 8.5 1 as an epidemic, and it now appears to have become 
domiciled at several places in that country. 

It is pointed out by Perkins that, in the eastern parts of Virginia, 
where severe malarial fever used to be very rare or sporadic, it has 
greatly increased in extent and frequency within the last ten years (the 
report dating from 1845) ; ^nd, according to the account of Trask, the 
same fact has been observed in the county of Winchester, N.T., where, 
about the year 1848, malarial foci sprang up in several districts hitherto 
entirely exempt, while at the same time there was no especial increase 
of the sickness to be made out in the neighbouring districts in which it 
was endemic. Within the last ten years similar obsei*vations have been 
made also in Pennsylvania and the New England States. In Con- 
necticut, says Burrows, malarial fever was common at the time of the 
first English settlement ; with the increasing cultivation of the soil, it 
disappeared almost entirely, being met with only in a few river valleys. 
In quite recent times, however, it has again become somewhat common, 
and it gets more and more widely diffused. This reappearance of 
malarial fever dates from the year 1866; New Haven was the centre, 
and in the years following down to 1872 the disease spread all round to 
Fair Haven, East Haven, Bradford, Guilford, North Haven, Hamden, 
and Meridan. Several observers in Connecticut have pointed out that 
the disease showed itself and got diffused at several points coincidently 
with the making of railway cuttings, the excavation of canals, and such 
like earth-works ; but we may take it that these are not the only cir- 
cnmstances in which the essential cause is to be sought, for the reason 
that malarial fever has subsequently shown itself in localities where 
that etiological factor is not available, and further by reason of the fact 
which many practitioners vouch for, that numerous other forms of 
disease have assumed a character peculiar to and typical of malarial 
sickness, and have proved amenable to treatment by quinine in a much 
more marked way than formerly. From this Burrows concludes that a 
kind of malarial diathesis has developed among the inhabitants, and 
in that way the general prevalence of the disease is to be accounted for. 
Also in the north of Europe, there has been noted at several points a 
striking increase of malarial fever within the past ten or twenty years ; 
particularly in Sweden and Finland, where, according to Hjelt, the 

1 'Reports of the British Army,' 1867, ix, p. loi, 1S68, x, p. 105, 1869, xi, 
p. 119, 1870, xii, p. 104, 15;irraut, Borius (II), Small and Power, Account in the 
'Lancet,' 1868, Feb. 22nd, p. 264, Mercurin, Parat, Edwards, Stone, Rogers, 
Welcb, Nicolas, Plaxall, Tcssicr, Lacaze, Passiguot, Mouestier, Labontc.' 


disease occurred first in epidemics limited to tlie south-western parts of 
the country, but has penetrated since the beginning of the present cen- 
tury, farther and farther towards the north and cast. 

Neiv ty2)cs. — Tho occurrouce witliiu the last twenty years 
of a severe form of remittent malarial fever, described under 
the names of Jievre hilieuse heniaturuiue, hamorrhagic 
■malarial fever, or fehris remitlens hamoi'rhay lea, is au 
interesting phenomenon in this connexion. This form of 
fever has been observed in various malarious localities in the 
tropical and subtropical regions of the Eastern and Western 
Hemispheres. There is no doubt that the malady, dis- 
tinctively marked as it is by hiematuria due to renal affection 
and by more or less intense jaundice from severe liver 
disease, had been observed by the practitioners of former 
times. We find indications of this in the descriptions which 
have been given by the French of " fievre bilieuse grave " 
and by the English and Americans of '' bilious remittent 
fever ;" but the disease has been frequently confounded 
with yellow fever, and it is only of recent years that we have 
arrived at a complete knowledge of it, owing, doubtless, to 
the inci'eased range over which it has shown itself and the 
general attention that it has attracted. 

The first exact data about this disease come from 

Madagascar and the Comoro Islands, from which we have 

accounts by Daulle (II), Monestier (I), and Borius (II). 

Later information on the same subject is furnished from 

Senegambia by Barthelemy-Benoit, Bourse (I), Chabbert, 

Serez, Leonard, Berenger-Feraud, Verdier, Rey (I), and 

Defaut ; from the Sierra Leone coast by Gore ; from Gaboon 

(Guinea Coast) by Forne and Abeliu, and by Dudon and 

Falkenstein from the Congo Coast. In Reunion and 

Mauritius, also, according to the statements of Monestier (II) 

and Labonte, many cases of that form of disease were 

observed in the severe epidemics of malaria which have 

occurred there since 1 866. For the continent of Asia, there 

is a single notice of its occurrence in India (Day, ' Indian 

Annals of Med. Sc,,^ 1859^ Jan., p. 105), and others from 

Cochin- China by Disser and Veillard.^ On the other hand, 

^ V. Leent mentions a " febris remitteus biliosa " in Sumatra, wbicb was 
■observed in Europeans only; it may perhaps be counted witb tbe above form of 
severe malarial sickness. 


this form of clisoaso appears to have attained a very wide 
diffusion in the West Indies (according to Pollarin (1^ III^ 
IV)^ Rufz, Manceaux and Rairnond for Martinique and 
Guadeloupe^ Sullivan for Havana, and Gibbs for Nicaragua) 
and still more in the Southern States of the Union. Almost 
all the authorities in those regions sjDeak of it as a disease 
hitherto unknown, or at least very rarely observed. In 
Texas it showed itself first in 18G6 (Ghent, Tate, Starley, 
Hewson, Johnson (II), Heard), and about the same time on 
the coast and in the central swamps of Louisiana (Barnes, 
Delery, Faget) ; thereafter in the State of Mississippi as far 
up as Natchez (Sharpe, in the ' Transact, of the Mississippi 
State Med. Soc. ^ for 1874), in Arkansas (Duval in the 
'Transact, of the Arkansas State Med. Soc. ' for 1871), and 
in Alabama, where it is prevalent to a very considerable 
extent, according to accounts by Kinnard, Scholl, Osboru, 
Michel, Riggs, Hendrick, Weatherley, Anderson, Mabry, and 
Webb ; it has lately been reported to occur also in North 
Carolina by Raleigh and Greene. 

The observations do not point as we liave said, to a new 
form of disease, but to an increase in the amount or frequency 
of sickness ; or, in other words, to the prominence assumed 
by several forms of malarial fever in places where they had 
previously occurred only as isolated cases, and had for the most 
part so escaped the attention of tke observers. This applies 
above all to the diffusion which the malady has attained within 
recent years on United States' soil. There is only one account 
hitherto pointing to the occurrence of this form of disease in 
the malarial regions of Europe, viz. one from Sicily ; in 
1877, Tomaselli published observations that ho had made in 
Catania of severe sickness in patients who had suffered for a 
long time from malarial fever and had used large quantities 
of quinine, and ho ventured to regard these complications as 
a result of quinine poisoning. When the communication 
was made to the Academic de Medecinc, it was pointed out 
by Lc Roy de Mericourt that the group of symptoms described 
by Tomaselli formed a complete picture of "febris remittens 
hsemorrhagica,'' and we find that this interpretation of the 
facts has been adopted by Maucini and Marotte in their most 
recent communications. 


We may here refer to still another form of malarial fever, 

■vvhicli was first described by the Uuited States' physicians 

under the name of typho-Tnalarial fever, and which attracted 

the general attention of the medical world on its appearance 

among- the American troops during the war of Secession. 

According to the account of Woodward, the disease showed 

itself first in the Federal Army in the autumn and early 

winter of 1861. The surgeons, who mostly came from the 

Northern States and were well acquainted with the phenomena 

of typhoid fever, were surprised to find in it a form of disease 

which had hitherto been strange to^ them. The course of 

the malady is sketched as follows by Woodward, from his 

observations in the Army of the Potomac. 

In those cases in wliicli tlie malarial affection predominated, tbe 
disease presented itself in tlie form of a simple intermittent or remit- 
tent ; not until after seven to ten days did the fever become continued, 
or the phenomena peculiar to typhoid show themselves, — diarrhea, ab- 
dominal tenderness, meteorism, delirium, dry and brown tongue, and the 
like. But it happened not iinfrequently that the symptoms peculiarly 
characteristic of typhoid were wanting, such symptoms as the diarrhoea 
and the rose-coloured spots, while pain in the region of the liver and a 
slight degree of jaundice were more frequent than in ordinary typhoid. 
Many of these cases ran a favorable course, especially under large doses 
of quinine, but deaths were not unfrequent. Post-mortem examination 
showed, as a rule, only a simple catarrhal affection of the mucous 
membrane with swelling and pigmentation of the solitary follicles and 
the Peyer's patches, and sometimes swelling of the villi in the small 
intestine with pigmentation at their apices. Corresjponding changes 
occurred here and there in the large intestine. Next in order, enlargement 
of the sj)leen was often found, and congestion of the liver with or without 
fatty degeneration. Histological examinations of the lymphatic follicles 
in these cases brought to ligJit changes such as accumulation of 
lymphoid cells, and sometimes their imj)action in the neai'est lymphatic 
vessels and in the connective tissue, which differed from the changes 
occurring in typhoid only in degree. Again, in those cases where typhoid 
infection was predominant, the disease took essentially the form of 
typhoid, and the post-mortem examination showed in a marked manner 
the changes proper to that disease. But the disease in question was 
characterised by the marked periodicity of its course ; the periodicity 
had often the typical intermittent character, becoming most pronounced 
in the defervescence and at the stage of commencing convalescence. 
Further, the enlargement of the liver and spleen was characteristic of 
malaria, and was not found in the same degree of development as in 
simple typhoid ; and finally, deposits of pigment (melaneemia) occurred 
in various tissues, as in malarial fevers. 


Earlier hiuts of tlie occurrence of this peculiar form of 
disease in tlic United States maybe found in the descriptions 
of its malarial fevers given by Drake, Dickson, and Wood ; 
researches on the same subject have been recently undertaken 
by Clymer, Flint, Loomis, and others, most of whom share the 
opinion of Woodward that we have not to deal hero with a 
peculiarly modified form of malarial fever, but with a hybrid 
4i,ffection, a combination of malaria and typhoid. 

The same form of disease has been described quite recently 
by Borelli for Naples, Aitken for Rome, Obedenare for 
Wallachia, Durand-Fardel for Chinese ports, and Maurel for 
ihe French convict scttlomeut on the banks of the Maraion 
(Cayenne). The description which these authors give of the 
course of the disease, corresponds in the main with the sketch 
of it by the United States' surgeons, but in their views of its 
nature they differ from the latter; Borelli, differing from 
most of his Neapolitan colleagues, who have expressed them- 
selves in the same sense as Woodward, holds to the view 
that the disease represents a modified form of typhoid ; 
Aitken, again, declares it to be a peculiar malarial fever, and 
Obedenare, Durand-Fardel, and Morel would also make it 
out to be a severe form of malarial sickness. The latter is 
the opinion expressed by Van der Burcht in his description 
of a fever observed by him at Gouda, which likewise showed 
the symptoms of a mild typhoid, but had remissions and 
intermissions in the latter part of its course, and proved 
thoroughly amenable to quinine and Fowler's solution. 
Finally, Colin in his essay on ' Typhoid in the Army ' also 
declares against the hybrid character of this disease ; ho holds 
it to be rather an unique malady, the result of a transforma- 
tion of malarial fever into typhoid. The data available at 
present as to this " typhoid malarial fever " afford no certain 
clue to its nature ; we may expect some enlightenment 
upon it in the immediate future, now that the attention of 
physicians has been directed to it at many points. 

An explanation of the fiuctuations in the amount of 
malarial disease at the several parts of the globe will be 
discussed in connexion with the question how far those 
diseases reach to in their geographical distribution, and upon 
what factors their limitation depends. 


§ 62. Regions of Intermittents, Kemittents, and Malarial 


By far the most frequent and most Avidely distributed 
form of malarial disease is the intermittent malarial fever, 
wliicli is mot witli at all times and in all places wherever and 
whenever tlic disease is endemic or epidemic ; in some cir- 
cumstances it represents, along with remittents of a mild 
type which very often change in tlie end into tho inter- 
mittent form, tho malarial process exclusively. This is true,.. 
above all, of the disease where it occurs endemically in higher 
latitudes ; and it is for the most part true of the epidemics of 
malaria in tho same regions, and still more of epidemics 
where the disease is not indigenous, the severer forms (re- 
mittent and pernicious fevers) being more likely to occur 
where the malady is endemic. This (intermittent) kind of 
malarial sickness accordingly, is met with most in the central 
and northern regions of Europe, on the rocky north coast 
of the Iberian Peninsula and tho plateau of Spain, in tho 
mountain districts of Upper Italy, in the tropical and sub- 
tropical regions of Asia little affected by the disease in 
general (Aden, Singapore, northern parts of China,^ Japan,, 
the southern slopes of the Himalaya),'^ on the table laud of 
Abyssinia,' on the prairies of the Eiver Plate States (especially 
those of Paraguay and Entro E.ios)j and of Australia, in 
many of the mountain valleys and on the tablelands of Peru,, 
New Mexico, and Texas, over the greater part of California, 
and, excepting on the shores of the great lakes, in the 
northern division of the'Eastern States of the Union, the- 
region of severe malaria beginning on the other side of New 

The severe remittent and 2^ermcions malarial fever is prin- 
cipally a disease of tropical and sub-tropical countries. Its 
headquarters are on the West African coast territories, from 
Senegambia down to the Congo coast, the coast plains and 
the numerous oases of Algiers,'^ the malarial countries on the 

' Morache. * Curren. ^ Blanc. 

'* Baclion (for the oasis of Lagliouut), Audct (for Tuggurt). Seriziat men- 
tions that in an oasis inhabited by about 400 souls, 15 adults and 30 children 
died of severe malarial fevtr in one vcar. 


East Coast of Africa, as given above, as well as ]\Iadagascar,^ 
the Comoro Islands, and tlic lately invaded islands of Mau- 
ritius and Reunion, the river basins and swampy levels of 
Abyssinia" and Khartoum, Lower Egypt (particularly the 
Isthmus of Suez'^), and Tunis ; on Asiatic soil the coasts of 
Arabia and Beloochistan, the plain of the Eujihrates, the 
malarial districts of India* and of Further India, Ceylon, 
numerous places in the East Indies (especially in Java and 
on the coast of Borneo), the southern and south-eastern 
coast belts of China and a largo part of its interior, the coast 
and the marshy plains of Persia'' and part also of its tableland, 
Syria, and the coast of Asia Minor and Transcaucasia. 

In the Western Hemisphere, the chief regions of remittents 
are : the coast, the valleys of the Sierra and the wooded 
region of Peru, Gayaquil, the sub-tropical provinces of the 
River Plate States (especially Tucuman), some parts of Chili 
where, as we have seen, a pernicious malarious endemic has 
lately developed, the marshy coast, plains, and damp river 
valleys of Brazil and Guiana, the coasts (especially the 
Atlantic) and damp valleys of Central America, the coast 
belt of Mexico, the malarious parts of the West Indies, as 
given above, the Southern and Central States of Union, with 
part of Pennsylvania, the prairie-lands (especially Illinois,^ 
Indiana, and lowa^), the shores of the lakes Huron, Erie, 
and Ontario within the limits above stated, and many districts 
on the western slopes of the Rocky Mountains (where the 
sickness is known as mountain fever^) including some of 
the Californian valleys,^ whereas the coast on that side of the 
North American continent enjoys an exemption from malarial 
fever, and especially from the pernicious forms of it. 

On [^European soil the area of endemic prevalence for 

' Borius (III), Borcligi-evinlc. ^ Blanc. » Anelli. 

< P^specially notorious in the liill-districts of the Dcecan under the name of 
" hill fever." See Wri-ht (IJ, Ileync, Macdonnel, Murray. 

* See Polak, and the account by Bell of the peruicious malarial fevter that 
prevailed in 1842 from the mouths of the Indus extending iu a north-westerly 
direction up to Teheran. 

•^ Hewins, Cook. 

7 Farnsworth. 

■^ Waggoner, Bartholow, Smart (II). 

^ Praslow, pp. 47, 49. 


the severe remittent and pernicious malarial fevers is a some- 
what limited one ; they arc most widely spread and most 
frequent in the steppe-lands of Southern Russia, in the 
Crimea, in the Ionian Islands, in some parts of Greece and 
of Turkey, in the Danubian Principalities, in the marshy 
districts and the low grounds of the Danube and the Theiss 
in Hungary, in the Banat, Istria, and Dalmatia, in the valley 
of the Po, in the malarious region of the Italian west coast, 
in Sardinia and Corsica, and on the southern and western 
coasts of the Iberian Peninsula. In more isolated spots, 
and on rarer occasions, we meet with this form of the disease 
as an endemic in the marshy valleys of Styria,^ in several of 
the regions of more intense malaria in France (La Vendee, 
Sologne, Charente, Landes, Bresse, Camargue), in the coast 
pi'ovinces of the Netherlands, in a part of Belgium," in a few 
marshy districts of Rhenish Prussia, and in the coast belts of 
Oldenburg, Hanover, and Holstein. 

The relation as regards sequence, of these severe malarial 
fevers to the simple intermittent form, is for the most part 
such, that at the beginning of the epidemic or the rise of 
the endemic, intermittent fevers are observed almost exclu- 
sively, that in the subsequent progress the cases of severe 
sickness become more and more numerous, predominating at 
the height of the endemic, again becoming relatively fewer as 
the amount of sickness decreases, while only intermittent 
forms are observed at the close. This ratio of severe forms in 
the endemic becomes the more pronounced the larger the 
dimensions assumed by it, or, in other words, the nearer the 
endemic approaches to an epidemic ; and when in such cases 
there comes to be an epidemic degree of prevalence even in 
those regions where malarial fever is not indigenous, the 
severe forms will sometimes show themselves to a consider- 
able extent there also,'^ although it is still in the proper foci 
of malaria that they predominate. 

1 Onderka. 

* According to Titeca, it still exists in Antwerp as well as in other places. 

3 At the time of the well-known seacoast epidemics of 1825-27, this relation 
came out very prominently in the comparatively frequent occurrence of severe 
malarial fever in Sweden, Denmark, and many of the non-endemic localities of 
Germany and France ; this was also the case at the time of later pandemics 
(1846-48 and 1855), particularly in Sweden, and also during the epidemic of 


As regards tho gcogra])hical distribution of the malarial 
cachexia, tlic principle holds good generally that it is most 
frequently met with in those more intense foci of malaria which 
give rise to tho endemic prevalence of tho severer forms of 
fever. Its development in the individual, however, is by no 
means dependent on preceding attacks of malarial fevers, 
but it may arise under the continuous influence of the 
morbid poison ; and it has often been developed, even in 
individuals who have remained entirely exempt from the dis- 
ease in its feverish forms. It is the malarial cachexia that 
contributes so materially to the excessive mortality found in 
malarious regions. 

§ 63. Regions and Circumstances op Quotidian, Tertian, 

OR Quartan Fever. 

The form and duration of the intermittent type of the 
fever in tho various parts of the globe that the disease fre- 
quents, is a question that comes into closest connexion with 
the inquiry concerning the geographical distribution of the 
several kinds of malaria. The general answer to this ques- 
tion is that the tyjies with shorter periodicity, approximating 
to continued fever — the quotidian and duplicated tertian — 
are proper to tropical and subtropical regions, while in higher 
latitudes the fevers with more prolonged intervals, viz. the 
tertian and quartan, are most characteristic. 

There is practically but one opinion among anthoritios as to the pre- 
valence of the quotidian type in the tropics. " In the tropics," says 
Day (II, p. 74), " the quotidian type assumes the proportion borne by 
the less fatal tertian in more temperate climes." Laure (II, p. 94) 
remarks, regarding the tropical colonies of France : " In the provinces 
occupied by iis the paludal fevers are almost always intermittent and of 
the quotidian type ; the tertian type is rare, and still rarer is the 
quartan." Dutroulau (I.e., p. 154) says: "Among the regular types the 
quotidian is most frequently recognised ; the statistics from all our 
palustral colonies prove this, and we may regard it as the general type." 
Frantzius (1. c, p. 326) states : " Costa Rica resembles other tropical 
countries in having the quotidian intermittent by far the most frequent 

1823-27 ill the British Isles, in which .nccordiiij:^ to my view, it is with mnlarial 
i'fvcr, and not, as Murchisoii afsuiiies, with relapsing fever, that we have to deal. 


&rm of ague ; the tertian occurs luucli more rarely, and it is ex- 
tremely seldom that one has an opportunity of observing the quartan." 
Less decidedly pronounced, but still clearly recognisaljle, this law shows 
itself also in higher latitudes, particularly in the Southern States of the 
Union, in the Ionian Islands,' in Greece," Turkey,-^ the Crimea,* and other 
parts of Southern Russia (as in Astrakhan, where Meyersohn estimates 
the quotidian type to be twice as common as the tertian) and even in 
Istria,* the Banat,*"' and;other malarious regions of Southern and Central 

A more particular analysis of tlie facts leads certainly to 
some conclusions that are in apparent contradiction to 
this law. But those are just the exceptions which enable us 
to formulate the principle more exactly ; which show, in fact, 
that the type of the fever stands in a definite relation to the 
intensity of the malarial process. We find, accordingly, 
that : 

1. The tertian type prevails in those regions within the 
tropics where the milder malarial fevers are indigenous, as, 
for example, at Aden,** the mountainous parts of the East 
Indies,' a few points in the Madras Presidency, and on the 
Peruvian coast, where the disease occurs in less severe 
forms than in the valleys of the Sierra or in the forest 
region. ^° 

2. In the malarious regions of the tropics, the natives 
take the milder forms of the fever, while the foreigners, and 
particularly those not acclimatised, take the disease in its 
severer forms ; and, in accordance with that fact, the types 
with lono-er intervals occur in the former and those with 
shorter intervals in the latter.^^ 

3. The frequency of the quotidian type in endemics or 

> Hennen, Ferrara. ' Faurc, p. 49. 

^ Rigler, Dumbreck. ■* Heiurich. 

5 Verson, Miiller (I). ^ Wenmaring. 

" In the marshes of Holstein, the types of fever, according to Dose, occur 
in frequency in the ratio of 20*5 per cent, of quotidian, 51 per cent, of ter- 
tian, 26'! per cent, of quartan, 2*4 per cent, of duplicated quartan, and o"3 
per cent, of pernicious fever. 

s Howison. 

3 Swaving. 

w Hamilton (I), Smith (II), Tschudi. 

'1 See particuhirly the accounts of Borius (I) and Chassauiol from Senegambia, 
the repart on the great malarial epidemics of 1809- 11 in India, and the special 
.accounts by Nash^ Henderson, and Morehead from the same country. 



epidemics is in direct proportion to the severity of tlie 

Thus Mondot states that, wlien the endemic malaria of SenegamLia 
takes a mild form, tertians prevail. The observations published by 
Shanks on the foi-ms of malarial sickness in an English regiment at 
Secunderabad from 1837 to 1841 are highly instructive in this respect; 
in the first year, when the endemic was little developed, all the cases 
were of the tertian type, while in the three following years, with the 
endemic at a considerable height of intensity, the quotidian type was 
ebsei-ved in five sixths of the admissions. As in the severe epidemics 
of ti'opical countries, so also in the recently observed appearance of the 
disease in Mauritius and Reunion, we always find the shorter type 
predominating ; the same holds good also in part for the severe malarial 
ejiidemics in higher latitudes, as, for example, in the sea-board epidemics 
of 1825-27, and in the epidemic of 1843 ^t Marienwerder,' and of 1859 
at Amsterdam. 

Finally^ we interpret in the same way the fact that 
4. In the endemic or epidemic prevalence of malarial fever, 
the tertian type occurs at the outset, whereas at the height 
of the endemic or epidemic, or whenever in general it assumes 
a severe character, the typo is quotidian, and as the sickness 
abates there are again the longer types of the fever, the 
tertian in tropical and subtropical countries, in higher lati- 
tudes often the quartan. We may recognise this behaviour 
of the disease even in the malarial centres of Charente,^ of 
Hungary,''' the Banat,* and of Transcaucasia,^ although it is 
more pronounced in lower latitudes such as those of Algiers,^ 
Senegambia,^ and India. ^ 

Morehead" observes with i-eference to the forms of the disease in India : 
" Quotidians will be found to prevail most generally at those seasons of 
the year when the generation of malaria is believed to be actively going 
on," and to the same effect are the reports of Day (II), and of Geddes 
(1)'° for the epidemic of 182,5 at Seringapatam, and for that of 1826 
at Caddapah. Concerning the behaviour of the marsh fevers around 
the Bay of Jahde, Wenzel states :^^ " The facts observed here agree 
with those observed elsewhere ; that is to say, when the morbific 
agent becomes more intense, as genetic power rises, there is not only a 
corresponding increase in the average severity of the form of sickness, 
but also a preponderance of the shorter rhythms and an approximation 
to the continued type ; Avhile, with decreasing intensity in the colder 

1 Heidcnlmin, p. 523. * Cordier. ■' Sdiolz, p. 315. 

* Weinberger. ■' Popoff, 1S57, pp. 52, 267. '* Haspel, Deleuu. 

7 Gauthier. « Geddes (II), pp. 94, 134. '■' P. 22. 

» Pp. 45, 127. "P. 23. 


montlis, there is a corresponding lengthening of the rhythm to tertian 
and quartan." I sliall have an opportunity of adducing further evidence 
on this point when I come to consider the question of the comportment 
of mahirial fever in the several seasons of the year. 

§ 64. No Race or Nationality immune — Acclimatisation. 

Just as tlic history of malarial disease shows it to have 
Leon a malady of all times, so the inquiry into its geography 
leads us to recognise in it a disease of all races and nationali- 
ties. This predisposition to malarious sickness is developed 
to the highest degree among all the peoples belonging to 
the Caucasian stock, not only on European soil, but also 
among the Arab population of the Barbary States/ and in 
the malarious districts of India, where the Mohammedan and 
Hindu population^ suffer in the same degree as the foreigners. 
This is not less true for the Malay^ and Mongol* stocks and 
for the native (Indian) population of North and South 
America.'' The predisposition is least for the Ethiopian race, 
which, although it by no means enjoys an absolute immunity 
from the disease, is still affected by it, ceteris paribus, less 
frequently, less readily, and less severely than other races ; 
and to this many experiences have incontestably testified, not 
only in Senegambia,^ the West Coast of Africa,^ Nubia,^ and 
other parts of its native habitat, but also in other malarious 

' Jacquot (II, p. 265), Espanet, Furnari, and other authorities for Algiers. 

2 Milroy, Huillet, Campbell, Winchester, Leslie, Thil, p. 18, Ollivier, p. 55, 
Morani, p. 21. 

3 Cameron, p. 71, for Ceylon; Epp, v. Hattem (II), and others for Amboina ; 
Heymann,p. 342, for Singkel ; Hodder, for the Andaman Islands; v. Leent (IV), 
for Sumatra. 

■* Wilson (I), p. 71, Duburquoy, Henderson (' Edin. Med. Journ.,' 1876, No. 
405), and others for China. 

5 See the accounts by Praslow, p. 44, and Keeney (' IT. S. Army Reports,' 
1855-60, p. 243), for California; by Moses (II), p. 38, and De Smet ('Voyage 
aux' Montagues Rocbeuses,' Gaud, 1849), for Colombia; by Thomas, Keller, 
Liherman, and Porter ('Amer. Journ. of Med. Sc.,' 1853, Jan., p. 36), for 
Mexico ; by Rendu, p. 69, for Brazil ; and by Tschudi, for Peru. 

* Thevenot (1), p. 245, Guuthier, p. iiC, Chassaniol, Berger, p. 51. 

' Daniell (II), p. 154, Gordon (I), Monnerot, p. 39. 

•'' Pruner, Hartmann. 


regions of tlie tropics whither they have migrated.^ This 
relative immunity from malarial fever on the part of the 
Negro race is an acquired and not a congenital ono^ as we 
may learn by the frequent cases of sickness and death from 
this disease among the children of the negroes in Sene- 
gambia. But the same immunity is enjoyed by the natives 
of all malarious regions so far as concerns their own home 
and such other localities as are alTected by malaria less 
severely than it; so that one might almost formulate a 
general rule that the predisposition to malarial sickness 
becomes weaker in proportion as the individual has been 
continuously exposed, from birth to maturity, to more or 
less severe malarial influences, without suffering from them 
to any considerable extent. 

Even in the malarious regions of Europe, in the Nether- 
lands,^ Belgium,^ Pola,* Syrmia and the Banat,'"* Rome^ and 
the Ionian Islands,^ the indigenous population sicken much 
less frequently and much less severely than persons who 
have come there from regions free from malaria. The same 
circumstance is reported from the Caucasus,^ the malarious 
centres of the Southern States of the Union,^ Algiers, ^^ Aden^^ 
and other subtropical parts of the globe ; but the fact comes 
out most clearly in the great malarious regions of India,^^ 
Ceylon,^^ Further India/* the West Indies,^^ Central America^" 
and other countries in tropical latitudes. The following is 

' Moulin, p. 21, and McCabe for tlio West Indies; Frantzius, p. 328, for 
Central America; Vaillant for Mexico ; Cameron for Ceylou ; Heymauu for the 
East Indies. 

* Blane, ' Obscrv. respecting Intermittent Fevers,' select dissert., London, 
1822, p. 90. 
3 Meynne, p. 273. ■• Erdl. ^ Wenmaring. 

« Colin (I), Aitken (' Brit. Med. Joiirn.,' 1873, March). 
7 Hennen, 'British Army Ileport«,' 1839, p. 34 «. 
'^ Kaputschinsky. 

'■* Le Conte for Savannah, Williamson (II) for North Carolina. 
"^ Furnari, Maillot, p. 265. 
'' Steinhauer. 

'" Annesley, McGregor, Stewart (' Transact, of the Calcutta Med. See.,' viii, 
p. 149), Macdougall, Twining (II), p. 207. 
'3 Marshall. 
'• Jacquet. 
'5 Hunter, EvaTis. 
IS Liddell, liuel, Horner (II). 



a table compiled by Waring^ of the malarial sickness during 
ten years among tlie troops in the Madras Presidency : 

Total strengtli. 

Admissions for 



Percentage of 
the troops. 



European troops . 
Native troops 





1 6-8 



The native troops accordingly suffered from simple mala- 
rial fever to a greater extent even than the European, but 
the number of cases of remittent fever observed was threo 
times less among the former than among the latter. In 
Ceylon there died of malarial fevers per 1000 of the popula- 
tion : 

Negroes . 

Natives of India . 


Natives of Ceylon 

Europeans (English) 






Also in the severe epidemic malaria of the Mauritius, 
according to the account of Barat, the coloured races (Kaffirs 
and Malagasys) have suffered less than others. In Costa 
Kica, says Frantzius (p. 32 8) , the severe forms of malarial 
sickness occur most frequently among the blond and blue- 
eyed northeners (Europeans) and the residents in the cooler 
regions of the highlands, while the settlers in the malarious 
districts and the acclimatised population are affected cither 
not at all or only with slight agues, negroes and mulattoes 
showing the greatest resistance to the malarial poison. 

It is in this sense, then, and notwithstanding all the objec- 
tions which have been urged on the ground of observations 
wrongly interpreted, that we may speak of an acclimatisation 
against malarial disease, assuming that the individuals have 
been exposed to malarious influences for a long time, and 
have escaped unscathed altogether, or been only slightly 
affected. But, on the other hand, it must be admitted that 
nothing so much increases the predisposition to the sickness 

1 P. 460. 


in general, and to the severe forms of it in particular, as 
repeated infection. This is the sense in which there is some 
reason in the contention of Dumontier/ Morel, Lecoq (p. 527), 
Monnerot (p. ig), Morani (p. 21), and the others, who deny 
the possibility of acclimatisation against malarial fever, on the 
ground of observations made for bodies of troops that had been 
stationed many years in malarious places in the tropics. 
The view that I have put forward receives a material sup- 
port from the most recent experiences of the occurrence of 
severe forms of hsemorrhagic remittent fever in the tropics, 
according to which, in the nearly unanimous opinion of 
observers,^ the sufferers have been almost solely Europeans,^ 
or, at all events, have never been the new comers, but only 
such as had suffered from malarial sickness many times 

Finally, there is a series of observations to indicate that 
the immunity gained by acclimatisation will prove insufficient 
in proportion as the severity of the epidemic increases, that 
it will be lost again if those who have been acclimatised stay 
too long in localities free from malaria, that it pertains only 
to the place in which it was acquired, and that those who 
remove to other regions of severe malaria will no longer 
enjoy protection from the sickness. 

In evidence of tlie first mentioned fact, the insufficiency of acclimati- 
sation in severe epidemics, tbere are many data from India, such as 
those of LangstafF respecting the great maUirial epidemic of 1829 at 
Delhi and other places in the North-West Provinces. On the second 
point — loss of immunity in consequence of too long a stay in regions 
free from malaria, — I adduce the interesting observations of Prichett and 
McWilliam made in the unfortunate Niger Expedition of 1 84 1-42 : out 
of 158 negi'oes who accompanied the expedition eleven sickened of 
malarial fever, and those eleven were persons who had lived for a long 
time (in England) at a distance from their native country. Pritchett 
adds that he had observed the same fact often befoi-e in the West Indies, 

^ ' Consideratious sur I'accliinatcinent des Europocns dans Ics pays cliauds,' 
Paris, 1866, p. 28. 

^ Daulle, Bourse (I), p. 17, Sercz, p. 38, Abeliu, Manceaux, Sharpe, Osborn, 
Sullivan, Pellarin, Veillard, Falkenstciu, Rcy (I), Defant. 

3 SclioU lias seen only one case of feljris liiuniorrliagica in a negro, and he had 
already gone tlirough many attacks of malarial sickness. Of 121 cases of this 
form of malaria observed by Poncervines in Mayottc, twenty-seven belonged to 
the coloured race and the rest to tlie Caucasian. 


and Gairdner' quotes from Captain Trotter's report on the same expe- 
dition, the statement tliat " the constitution of the negro, whether of 
African or American birth, requires an habitual residence in Africa to 
be exempt from the fever of the country." Lastly, for the insufficiency 
of acclimatisation where there has been a cliange in the malarious place 
of residence, there arc various interesting pieces of evidence from 
different malarious countries in the tropics ; thus, according to Grier- 
son, Sepoys from India prosier sickened on the marshy soil of Arracan 
in almost the same numbers and to the same degree as European troops ; 
in Burmah, according to Day, two thirds of the Sepoys suffer from the 
severest malarial fevers; and Beatson^ observes that Indian troops 
coming from Hindostan to Chittagong run a great risk from malaria. 
Natives of St. Louis (Senegambia) who migrate to Bakel, are subject to 
malaria there almost as much as Europeans ; the same fact is stated by 
Michel (I) with reference to the Senegalese who have migrated to the 
Gold Coast, and by other observers for negroes from Guinea who come 
to the Island of San Thiayo — one of the Cape Yerd Ai-chipelago, and 
known as " Mortifera " from its deadly climate — and there incur the 
same risk as other foreigners. 

§ 65. Influence op Climate and Season. 

Among the factors which determine the occurrence and 
diffusion of the malarial diseases, climatic and telluric condi- 
tions hold the first place. 

The dependence of malaria-production on climatic influ- 
ences, of which the geographical distribution of the disease 
over the globe has already given us indications, is brought 
out in the most definite way by the prevalence of malarial 
fever (i) at certain seasons and (2) under certain meteoro- 
logical conditions, particularly under the influence of heat 
and atmospheric moisture. 

In those localities where malarial diseases are endemically 
prevalent, they occur at all seasons of the year ; but we 
everywhere meet with maximal and minimal periods of sick- 
ness, and it is with the maximal periods that those epidemics 
are associated which spread beyond the malarious districts 
to localities where the disease is not indigenous. A compa- 
rison of these seasonal periods of maximum and minimum for 
the several malarial regions, shows many differences among 

^ 'British Army Report' for 1865, p. i^$. 
" Pp. 60, 62. 



thcm^ while there is a certain uniformity witliin particular 
latitudes. Thus, we find that : 

I. In regions with moderately developed malaria, there are 
two maxima, one in spring and one in autumn, a considerable 
decrease of the disease in the months between them, viz. in 
summer, and a minimum in winter. 

This kind of incidence of the sickness is met with in 
many localities belonging to higher latitudes, — in Sweden, 
Denmark, the north of Russia, Poland, a great part of Ger- 
many, and the north of France, and in high-lying or moun- 
tainous regions of tropical or subtropical latitudes corre- 
sponding to the above, such as the tableland of Mexico.^ 

A closer examination of the circumstances in these cases 
will convince us that the autumnal maximum occurs oftenest 
wherever the malaria is most intense, and that the great 
epidemic or pandemic outbreaks of the disease usually reach 
their height, therefore, in late summer or autumn." The 
details summarised in the three following tables furnish 
striking examples of these ratios in the amount of sickness. 

Table of Malaria throughout the Year in Temperate Regions? 

Sweden. 1 

of Jiilide. 












February . 














April . 







May . 







June . 







July . 














September . 














November . 







December . 







2. In regions with strongly developed malai'ia, there is a 
maximum beginning in summer, which reaches its height at 

^ Newton. 

- This incidence of the disease comes out very clearly in the great malaria' 
epidemics of 1S07-11, 1824-27, and 1S46-49. 

' For footnotes to tliis and the following table see bottom of p. 250. 



tlio end of tlic summer or the beginning of autumn, lasting 
not rarely into the winter, and wliicli so far exceeds the 
spring maximum that the latter not unfrequently disappears 
altogether, so that there is only one minimum, winter and 
spring, and one maximum, summer and autumn. 

This is the curve of the disease that one meets with 
mostly in warm or subtropical regions, such as southern and 
western France, Italy, Sicily, Sardinia, and Corsica, the 
Iberian Peninsula, Southern Russia, Hungary, the Banat, 
Dalmatia, Algiers, Tunis, Egypt, Syria, Persia, Transcau- 
casia, and the Central and Southern States of the Union. 
In all these countries, the more extensive epidemic outbreaks 
happen in the summer and autumn months, chiefly from July 
to October (sometimes as early as June), and they may then 
last through part of the winter, into December and even 
later. From numerous observations confirming these state- 
ments, I have drawn up the following table giving a series of 
statistical data for a number of localities. 

Tabic of the Incidence of Malarial Fever throughout the Year 

in Warm Countries. 



United States of America." 
































January -. . 








February . . 






\ 3S 



1637 2864 



March . . . 







April . . . 







May , . . . 






< 202 



2842 3807 



Juue . . . . 







July . . . . 






August . . . 






< 796 



2638 5506 



September . . 






October . . . 







November . . 





1 5-8 




2381 5653 



December . . 







3. Finally, in the most intensely malarious spots of the 
tropics, the prevalence of the disease is generally associated 
in a most marked manner with the rainy season ; the fever 
usually makes its appearance with tho commencement of the- 


rains, and lasts through the whole of that period ; if the rainfall 
be not excessive, it reaches its maximum usually when the 
rains cease, and continues with decreasing extent and viru- 
lence, until the setting in of the cool season. But inasmuch 
as the rainy season in the several regions of the tropics has 
somewhat different times for setting in and a varying duration 
according to the geographical position and the configuration 
of tlie country, there are also very considerable differences 
in respect to the time when the sickness is prevalent in the 
several tropical malarious countries.^ 

Further, the period of fever is protracted much longer here 
than in the localities of which we have already spoken, 
not unfrequently, indeed, far into the so-called cold season ; 
and this holds particularly for those regions where the 
differences in temperature are the least marked between the 
several seasonal periods, and applies therefore more to the 
tropical regions of the Western Hemisphere, especially the 
West Indies and Guiana, than to those of the Eastern. The 
following table makes clear the conditions of sickness which 
we are now considering, for a number of points within the 

' Sec McClelland, p. 120, v. Frantzius, p. 319. 

' From tlic reports of the Swedish Board of Health (' Suiidhets-CoUeg. 
Berattelse ' for the years 1820-73. 

- According to Wonzel for cases of sickuess among harbour labourers in the 
years 1860-69. 

^ According to Thomas (II), p. 233, from twenty-three years' observations in 
public institutions for the sick, and in practice among the poor. 

^ Hussa, from ten yeai-s' admissions into the General Hospital. 

"* The same, from twenty-five years' observations. 

" Dose, from observation of 6896 cases during the years 1842-63. 

' Petit, from observation for twenty years. 

'^ Lach for three years (1S54-56). 

'■> Bailey, 1. c.. May, p. 401, IVom the admissions at the Military Hospital of 
S. Andre, 1858-60. 

'" Baccelli for two years' observations in hospitals at Home. 

" Jilek, p. 26. The numbers give the proportion of sickness in the total force 
of troops for the years 1863-67. 

'- Villettc, from several years' observations among the French troops in 

^* From the ' U. S. Army Reports' for the years 1839.59. 



Table of the IncidcncG of Malaria throur/hout the Year in 

Tropical Countries. 





»— t 

H- 1 









January . . 















■< 416 



March . . 







April . . . 







May . . . 







i 234 



June . . . 

1 19 






July . . . 







August . . 






1 £'65 

\ 746 



September . 







October . . 







November . 



1 561 




' 936 



December . 








§ 66. Influence op Heat. 

The question here raised leads us to inquire into the 
influence on tlic production of malarial disease exerted by 
those factors that are characteristic of the climate — by the 
conditions of heat and moisture. That inquiry rests directly 
on our knowledge of the geographical distribution of malaria, 
and the facts given in the course of the foregoing sketch 
find a definite expression in the law that the disease shows a 
progressive decrease both in extent and intensity from the 
equator to the poles, and that there is a certain limit beyond 
which it does not occur either endemically or epidemically, 

1 Reports by Stowell, p. 6, and Waring, p. 464, on the admissions for fever 
into the General Hospital of Bombay, 1838-43, and 1846-56; the figures give 
the ratio per month in each 100 cases in the year. 

2 Day (V), p. 240, from ten years' observations in the Civil Dispensary. 

3 Day (I), p. 56, from five years' observations among the troops. 

4 Ewart, p. 464 J the figures show the proportion of sickness in every 
100 soldiers. 

5 Geddes (II), p. 87, from five years' observations among the troops, as in (i). 
^ Day (II), p. 57, also reckoned as in (i). 

' Dutroulau, p. 9, from two years' observations in the hospital at St. Louis. 
s The same, p. 18, from the hospital in Cayenne during two years. 
9 The same, pp. 30, 31, from two years' observations in the hospitals in 
Martinique and Guadeloupe. 



or, if it do occur, then only in cases imported. In the 
Soutliern Hemisphere, where this limit is found within com- 
paratively low latitudes, the limitation is undoubtedly more 
dependent upon telluric than upon atmospheric influences. 
But the circumstances in the Northern Hemisphere must be 
judged otherwise ; here the limit corresponds to a line which 
starts from 55° N. on the western side of North America, 
sinks to 45° on its eastern side, rises to 63° or 64° on the 
western side of the old world (Sweden and Finland) and runs 
across Northern Asia in about the latitude of 55°. In the 
following table I have put together two groups of observations, 
the first of which contains a series of places just within the 
limit where malarial fever is endemic or epidemic, while 
the second embraces points that lie beyond the limit and are 
free from the disease (except as imported) notwithstanding 
the presence of some factors, notably in the soil, which are 
favorable to its production. 



Mian temp, 
of tlie yew. 

Mean summer 

''Quebec (Canada) 




Kingston (Canada) 




I. - 

^ngermanland (Sweden)' 




St. Petersburg 




^Barnaul (Siberia)^ 




'New Arcbangel (Alaska) 




Fort Ripley (Minn.) . 




Fort Kent (Maine) 





St. John's, N.F. . 
Julianehaab (S. Greenland) 




Iceland .... 




Faroe Islands 



__Haparanda .... 


- o°25 


From this we may conclude that the summer isobar of 
150_16° C. (58°— 60° Fahr.) marks the limit^ of the occur- 

1 From raetcorological observations iii Heniosaud. 

" This is tlie farthest point in Siberia from which there arc any accounts 
known to me of malarial fever occurring. 

' Wenzel (p. 20), from observations made in 1858-69 among the harbour 
labourers in the district of Jahde, arrives at the confirmatory result that a 
temperature of 12" Iv. (15" C.) is the limit for the development of malaria there 
in the summer (piarter. 


rence of malarial fever, and tliat tlioso regions wlicre the 
mean summer temperature docs not reach that height, are 
exempt from the disease. A rather high temperature, 
therefore — and the opinions of all observers agree in this — 
forms an essential condition for the development of malaria ; 
and one would be justified in ascribing to this factor, within 
limits at least, the manner of diffusion of the disease over 
the globe, attributing to the higher temperatures the pre- 
dominance of the disease in tropical and sub-tropical regions, 
and to the relatively lower degrees of heat the less frequent, 
milder, and less persistent forms of temperate latitudes. A 
confirmation of this is found not only in the circumstance 
that the extent and intensity of the disease in malarious 
foci at the several seasons of the year are in direct pro- 
portion to the height of the respective temperatures, but 
also in the fact that the great epidemics or pandemics have 
been immediately preceded by hot years or have coincided 
with them. 

" The severity of these diseases " (intermittent and remittent fever), 
says Annesley (p. 39), writing of India, "is generally in proportion to 
the warmth of the climate or season in which they occur." To the same 
effect is Morani's opinion from Cochin China : " The observation is 
made every day, that it is almost always at the moment of greatest 
heat that the fever declares itself;" and the same opinion is expressed 
by Serez (p. 38), by Gauthier for Senegambia,jby Yon Frantzius (p. 519) 
for Costa Rica, by Caddy for Mexico, by Levander for Alabama, and by 
Armand (p. 131), Come, and others for Algiers. Similar observations 
have been published from temperate latitudes, as, for example, from 
Rome by Bailey, who says (p. 428) : " To this period of greatest heat 
(July and August) there corresponds the greatest pathogenetic eleva- 
tion in the whole year ; the march, so to speak, of the temperature and 
of the pathogeny is the same;" and this is confirmed by Barudel (p. 118) 
almost in the same words. It is further affirmed, by Jilek (p., 57) 
for Pola, by Willkom for the plateau of New Castile (Spain) and 
Valencia, by numerous authorities for Tennessee, Virginia, Pennsyl- 
vania, and other of the Central States of the Union, and for Belgium 
by Meynne, who remarks (p. 226) : " During hot summers the fever 
acquires more intensity and greater extent than in ordinary years. 

. . . We may, indeed, establish a general rule that the intensity 
of the paludal miasm is regulated by the intensity of the heat." Still 
further, by Goldschmidt and many other writers for the malarious 
localities on the northern coast of Germany, by Mondineau (p. 13) for 
Landes, by Tessier for the Sologne, and by Godelier for Charente. So 

254 GEOGRArnrCAL and historical I'ATHOLOGY. 

that Avlien Dutroulau, in summing up all these facts, says (p. 165): 
" The steady rise of the thermometric mean in warm and palustral 
climates must be regai-dcd as nnqticstionably a more potent aiding 
cause of endemic fever than the sudden rise of the thermometer in 
certain localities " — he expresses not only the view of observers in 
tropical and sub-tropical regions, but also the purport of the obseiTa- 
tions that have been made in higher latitudes. As to the coincidence of 
great epidemics or pandemics of malaria with remarkably hot years, 
there are likewise many observations from the most diverse parts of 
the globe ; among others, for the extensive and severe epidemics of 
1809 — 181 1 in Mysore, and of 1829 and 1841 in the Noi-th-West Pro- 
vinces, the epidemic o£ 1853 in Amboina, where, according to the 
account of Popp (p. 14), the pestilence appeai-ed with calms and a very 
high state of the thermometer following heavy rains, (" in die mate, dat 
de oudste zich met herinnerdcn, eene dergelijke saisonsvcrandering te 
hebben bijgewoond,") the epidemic of 1829-30 in Brazil (Sigaud, p. 170), 
many severe epidemics in the Netherlands and Germany (Alkmaar in 
1556, Friesland in 1748, Amsterdam in 1834, Bruges in 1842, and the 
general prevalence of the sickness in 1719, 1807, 181 1, 1826, 1846-47, 
and 1855), the eijidemic in England in 1657 (Willis), that of 1831 in 
Sweden, and that of 1834 in Denmark (Bremer). 

But althougli tlicrc can be no reason to question tlie 
general importance of high temperature for the production of 
malaria, there is just as certainly another series of facts 
which serves to keep that significance within due limits. On 
the one hand we meet with the fact, noteworthy in this con- 
nexion, that, in higher latitudes, the malarial fevers which 
have prevailed endemically or epidemically in spring- 
undergo for the most part a considerable remission on the 
setting in of summer heat, that they do not revive until the 
cooler weather of autumn, and that the disease has often 
attained a wide diffusion in spring during remarkably raw 
and cold weather (as at Halle in 1701, in Dalecarlia in 1772, 
Copenhagen in 1724, Liineburg in 1797, Riga in 1799, 
Baireuth in 18 12, Wilrzburg in 1824, and various places in 
North Germany in 1847). I^ is this that has led Huss to 
conclude from his Swedish experiences (p. 83) : *"' en laug, 
kylig og fuktig vai* alstrar stiidse et storre antal frossfebrar, 
an en kort, mild och torr.^' Next there is a circumstance 
not to be left out of sight, that, in the regions of severe 
malaria, the disease shows itself and attains a wide diffusion, 
not at the height of summer, but only when the high 
temperature is declitmg in late summer and in autumn, and. 


for the tropics in particular^ at the end of the hot season. 
And, as many observers state, this is directly due to the great 
diurnal range of the temperature that occurs at that season. 

Twining (II, p. 207) expresses liimself very decidedly on this point, 
basing on his experience in Bengal : " The freqxxency of intermittents 
is augmented beyond all j)roportion after the cold nights and foggy 
mornings commence, and when the heat of the day, though much 
decreased, is followed by a greater degi'ee of depression of the thermo- 
meter during the night than happens at any other season of the year;" 
and the same opinion is stated by Geddes (II, p. 163) for Madras, by 
Nicoll and Day ('Indian Annals of Med.,' i8,'^9, Janiiary, p. 88) for the 
Deccan, by Hamilton for Honduras, by Cambray, Worms, Phillippe, 
and others for Algiers, by Aubert-Roche for the Arabian coast, by Forchi 
and Fourcault for Rome, by Faure (p. 47) for Greece, and by Kaputs- 
chinsky, Popoff, Sachs, and others for Southern Russia. Nepple, 
■whose experiences relate chiefly to the Bresse country, says (p. 135) : 
" It is an indisputable fact that this malady does not prevail equally 
at all seasons; that it is not until the end of summer, or, in other 
words, during the period which dii'ectly follows the great heats, that a 
large number of persons are attacked at once," adding, at the same 
time, that the extent and severity of the sickness is in dii'ect proportion 
to the high degree of heat in the preceding summer. Severe epidemics 
of autumnal fever, in somewhat cool weather, have been observed in 
1615 and 1684 in various x^'T^rts of Germany, in 1657 in England, in 
1724 and 1726 in Paris, in 1764 in the Bresse country, and in 1835 in 

It is further of some account for the question before us 
that the endemic and epidemic malaria of the tropics dis- 
appears on the setting in of the so-called cold season, or, in 
other words, that the disease occurs there only sporadically 
with a temperature at which, in higher latitudes, malaria still 
continues in full force and potency. Finally, there is the 
fact that in regions with a temperate climate, and even with 
a climate reckoned as cold, not only has an epidemic which 
began in the autumn, continued through the winter, but also 
that epidemics of malaria have even developed under a 
winter temperature. 

Frank> observes : " I have several times seen at Wilna intermittent 
fever showing itself in the month of February when the thermometer 
showed 20° R. of frost and even more ;" in Kasan, as Blosfeld tells us, 
an epidemic of malarial fever occurred in the winter of 1841-42 in the 

• 'Prax. med. univ. praecepta,' [De febre iutermitt., § xxvii, 9 Lips., 1826, i» 
p. 262. 


midst of severe cold ; Meyersobn (p. 259) wi'ites fi'om Astraklian : " It 
is a fact that the fever was prevalent even when the thermometer 
showed twenty degrees of frost and more ;" and Walter (p. 99), speaking 
of KiefF, says : " In our eastern governments [of Rnssia] the epidemics 
of fever show themselves even when the whole country lies under a 
firm covering of ice ; and, if the statements of physicians, which I have 
had the opportunity of hearing, are correct, they reach a higher inten- 
sity than in the hot summer time. That ten or fifteen or twenty 
degrees of frost does not with us ward off fever, is proved by the 
scarcity of quinine, which is much felt in the months of December and 
January, if the supply of the drug have been used up in the course of 
the year." 

If wc would riglitly stato tlieso etiological questions, and 
correctly interpret tlio answers to them, we should, in my 
opinion, agree to the declaration of Jacquot : ^ "if the rise of 
temperature cannot of itself create the fevers, it appears as 
if it were capable of increasing their frequency and gravity ;" 
while we must at the same time recognise the fact that the 
relations of malarial production to influences of temperature 
are by no means so simple as we have been accustomed to 
deem them. 

§ 67. Influence of Moistuee — Rain or Dew. 

An influence on the development of the disease not less 
pronounced than that of the temperature is exerted by the 
degree of at7nospheric moisture, or of the atmospheric pre- 
cipitations that result therefrom. Usually this influence is 
manifested in the occurrence of malaria, or in an increase in 
the amount of sickness, after copious rains, especially if they 
be followed by dry weather and a high temperature. But 
inasmuch as this etiological factor really deals with the 
saturation of the soil caused by the precipitations (rain and 
dew), and with the fact to be afterwards proved that the 
saturation, when complete, sets limits to the development of 
the malaria, then it is self-evident that we are always con- 
oerntxl here with a certain measure, or with the relative 
amount of the precipitations. This mean or measure will 
.•stand in a definite ratio to the condition of the soil ; the fall 

1 ( 

Gaz. metl. de Parip,' 1848, p. 589. 


must be all the more copious, if it is to aid in the pro- 
duction of the disease, -when the soil is naturally dry, while, 
on the other hand, a very heavy fall on a naturally wet soil 
will prevent the development of the disease till such time at 
least as the soil has again become in a measure dried through 
the evaporation or sinking down of the moisture within it. 
This law, deduced from a long series of observations, is 
on the whole Avell borne out by circumstances ; but hero 
again there are a certain number of prominent facts that do 
not suit themselves to it, — a good many contradictions of 
which the explanation is still to seek. 

In the malarious regions of the tropics the fevei's appear, 
as a rule, at the beginning of the rainy season, they increase 
in extent and severity with the increasing rain-fall,^ remit 
usually at the height of the rains, especially if they be very 
lieavy,^ and reappear towards their cessation or directly after 
the rainy season, which is, as a whole, the season when the 
conditions are most unfavorable to health. Showers of 
rain, also, in the hot season, and all alternations between 
drought and moisture, are usually followed by an exacer- 
bation of the endemic f and one may often detect a direct 
relation between the extent and severity of the endemic or 
epidemic and the degree of the preceding rainfall. 

" Increased moisture leads to increased admissions for fever," says 
Day/ speaking of tlie Deccan, and opinions of the same purport are 
given by Annesley (p. 523) for Bengal, Geddes (p. 94) for Madras, Grie- 
singer (after Penay) for Khartoum, Aubert-Roche for the Arabian 
-coast, and by others. Side by side with these accounts from the trojiics, 
of severe malarial epidemics after continuous rain, there are communica- 
tions by Langstaff for Delhi in 1829, McGregor for the plain between 
Delhi and Karnaul in 1841, Spencer for Moradabad in 1836, Geddes (I) 
for Kaddapah in 1826, and by^Sigaud for Brazil in 1829-30. To the same 
category, also, belong the reports of severe epidemics in Honduras in 
1861,* and Ramandrag in 1863.'"' 

1 Aunesloy, p. 520, Pritchett, p. loS, Bernouilli, Day (V), p. 240, Griesinger, 
p. 374, V. Frautziiis, p. 319, Vaillant, p. 12. 

* Primer, Meller, Forbes, v. Frantzius. 

^ Geddes (II), p. 136, Day, 1. c., v. Frantzius. Blanc observes that in 
Massowab [Red Sea] tbe smallest precipitations suffice to call up the malaria. 
■* 'Indian Annals,' 1858, Jan., p. 71. 

* ' British Army Reports,' i86i, p. 73. 

^ 'Madras Quart. Journ. of Med. Sc.,' 1863, Julv, p. 118. 



The facts come out practically tlie same in subtropical 
regions and in higher latitudes. There also we find : 

1. Malarial fever appearing as an endemic or epidemic 
either Avhen the rains set in after a long period of heat and 
drought, or, again, when the rains cease and give place to 
Avarm and dry weather. 

Thus Link relates that when the first rain fell in Athens in the begin- 
ning of October, 1838, after a summer that had been very hot and dry 
all through Greece, every hospital in the city became filled with the sick 
all at once. Under the same or at least similar circumstances, malarial 
epidemics sprang up at Lucca in 1648, at Rome in 1795, at Olmiitz in 
1783, in Walchercn in 1S09, at Zevio in 181 1, at Rimini and La 
Rochelle in 1827, in Istria in 1833, at Grenada (Haut Garonne) in 1845, 
at Emden, at Brcslau, and in Galicia in 1846, at St. Maure (Indre-et- 
Loire) in 1848, and at Fiirth in 1859. With regard to the disease 
increasing as the rains cease and dry and warm weather sets in, Hip- 
pocrates had already said ■} " If the winter be of a'dry and northerly 
character and the spring rainy and southerly, there will necessarily be 
acute fevers." 

We meet with numerous epidemiological experiences corresponding 
to this ; thus, the same sequence has been observed in North Carolina, 
according to Dickson,^ at Fort Merrill, Texas (Moses),^ in Algiers 
(Jacquot^ and Bachon), on the Siberian Steppes (Woskesensky and 
Rex), and in the Danubian Principalities (Lcconte).'' 

2. The endemic or epidemic dies out at the height of the 
rains if they are abundant. 

In Sardinia, says Moris, the endemic attains its acme in [autumn 
whenever the first rains set in, and begins to decline only when the 
plains are entirely under water ; this phenomenon came out very 
markedly, according to Button, in the epidemics of 1823 and 1824 in 
Delawai-e County, Pennsylvania. 

3. The disease is common in wet years and of rarer 
occurrence in dry years. 

With reference to the prevalence of malarial fevers in the ^Southern 
and Western States of America, Cooke (I) says : " Wet summers are 
sickly and dry summers are he;ilthy," adding the noteworthy remark : 
•' except in the neighbourhood of marshes, ponds, and rivers," and he at 
the same time calls attention to the enormous diffusion of the disease 

1 Aphorism, iii, § 1 1 (Eil.Littre iv, p. 4130, ip' /.liv 6 xnnuv av)^fir]p'o£ Kai jSopuoi: 
-/'iV7]Tai,To Ci tap tnofiftpov koi voriov, ura^icij, tlv Oipioc, nvpirovc'^o'^eac), 
- ' U. S. Army Et'iiorts,' 1856, p. 353. 

^ni),p. 75'- 
^ r. 20, 



in Pennsylvania, Maryland, Virginia, OLio, Mississippi, and Alabama 
in the very rainy year of 1 823. Sutplien expresses a similar opinion for 
the State of Michigan, Williamson for North Carolina, Meynne' for 
Belgium (with special reference to the wet year of 18,1^9 when there was 
much fever as compared with the dry year of 1858), Schroder- for South 
Bavaria, Bailly^ and Colin' for Rome, Ely for Paestum, Troussart and 
Gaucher (II) for Algiers, and Rafalowitsch for Syria. For certain 
localities this ratio between the quantity of the rainfall and the amount 
of sickness is proved by statistics ; for example, the following table is 
given by Jilek for Pola. 







Rainfall, in Paris inches . 
Cases of fever, per 100 men 










The apparently contradictory results for 1865 and 1867 are explained 
on the one hand by anomalous conditions of temperature, and also by 
the great differences, as regards malaria production, between moderate 
falls of rain in rapid succession and the same distributed over longer 
periods. Armand* remarks that in the year 1843, i^ which there was 
hardly any rain in Algiers from May to October, the number of admis- 
sions for malarial fever among the French troops was 52 per cent, of 
the .effective force, while in the previous rainy year it was 71 per cent. 

According to Pendelton,*' the i-atio of sickness to rainfall in the 
malarial fevers of Central Georgia may be represented as follows ; 






Rainfall in Spring and Summer'' . 
Rainfall in Autumn . . - . 
Amount of sickness^ . 













1 p. 336, 2 p, J 00. 3 p. J 2 7. 

■* (II), p. 75. " It is a general rule," he says, " that the more rainy the year 
has been, previous to the breaking out of the fevers, the graver and more numerous 
these are ; while, on the other hand, there is a minimum of sickness in dry years, 
even if they he very warm, as we found in 1865." 

^ (1% P- 1.^2. 

^ •Southern Med. Reports,' i, p. 327. 

7 The figures give the amount of rain as calculat:d with relutiou to the mean 
rainfall = i. 

8 Proportion of malarial sickness per hundred of all cases of disease observed 
by the author in the same period. 


But there arc still, as we have said, many unexplained 

exceptions to the rule, which serve to show how far we are 

at present from having a complete insight into this particular 

factor. In the years from 1868 to 1872, an enormous 

increase of endemic malarial fever was remarked in India ; 

this striking phenomenon was particularly obvious in Madras, 

Avhere the mortality from malarial fevers was : 

In 1868 . . . 105,692 

» 1869 . . . 132,346 

„ 1870 . . . 151,027 

„ 1871 . . . 193,398 

But the years 186S and 1871 were notable for the almost 
complete absence of the north-east monsoon, and still an 
increase in the amount of sickness was uniformly remarked 
all over the Presidency;-^ in 1872 abundant rains appeared 
again, but in that year a very noteworthy decrease in the 
amount of sickness took place. In the official accounts of 
the state of health in India in the years 1872 and 1873, it is 
explicitly stated that there, as well as in other regions of the 
tropics, wet years have very often been distinguished by a 
highly satisfactory state of health, and dry years by very 
unfavorable sanitary conditions. Thus, in the year 1869, 
there was a widespread epidemic of malaria in the Punjaub, 
the North West Provinces, and down to the mouth of the 
Indus ; and, as Cunningham points out," the one factor that 
could not be held responsible for the outbreak of the disease 
over that great tract of country, was the saturation of the 
soil. Another fact in this connexion is noted by Wenzel f 
on comparing the rainfall for twelve years, while the harbour 
works in the Bay of Jahde were going on, with the corre- 
sponding annual amount of malarial disease, he found that 
the popular opinion prevalent there, that want of rain and 
great drought favoured the rise and diffusion of malaria, 
was no more applicable to that district than the converse 
view, and " that a saturated state of the ground, and the exact 
opposite, were almost indifferently concerned in the production 
of marsh malaria." Thus, he observed : 

^ Account iu the 'Madras Monthly Journ. of Med.,' 1872, v, p. 298. 
^ ' Tcntli Annual Report of the Sanitary Commissioner with the Government 
of India,' 1873. Calcutta, 1874. 
3 P. 146. 


In three years (1858, 1859, and 1868), severe epidemics 
with a rainfall of 2" to 4" below the annual mean. 

In one year (1861) a severe epidemic Avith an excessive 
rainfall, 5'25" above the mean. 

In two years (1862 and 1863) severe epidemics with a 
rainfall that diverged from the mean scarcely at all. 

In 1865 a slight epidemic with a deficiency of more than 
6", and in 1866 a second slight epidemic with an excess of 
2" of rain. 

On two occasions, with a great excess of rain in all the 
four seasons of the year (i860 and 1867), and on one 
occasion, with a great deficiency (1864), there was no 
endemic prevalence of the disease whatsoever. If we take 
into account all the other allied meteorological factors, such as 
temperature, clouds, and the like upon which the evaporation 
depends, we may still safely conclude with Wenzel " that the 
production of malaria in a marsh is neither unconditionally 
furthered, nor unconditionally hindered by the saturation or 
by the dryness of the ground, nor indeed influenced in any uni- 
form and regular way." The fact that epidemics of malaria 
coincide in general somewhat more frequently with drought 
than with abundant rainfall, depends less, as Wenzel adds, 
upon hydro-meteorological than upon other weather conditions, 
particularly the temperature, which is lower on an average in 
wet years than in dry.^ 

§ 68. Influence op Winds. 

In considering the question of the influence which winds 

exert on the occurrence and diffusion of malaria, we have to 

take into account, on the one hand, the property of the air 

in motion as a carrier of material substances, or of the 

morbid poison, and, on the other hand, its modifying effect 

upon the statical conditions of atmospheric heat and 

1 In Dittmarschen also, as Dose points out, severe endemics coincide with 
dry years, and the milder endemics with wet ; but here the difference is much 
more pronounced than in the Jahde district. Thus in the wet years of 1842-46. 
1849-51, 1856, and 1863, there occurred in all 1242 cases of malarial sickness, or 
a yearly average of 124-2 ; while in the dry years of 1847-48, 1852-55, and 1857- 
62, a total of 5614 cases were observed, or a yearly average of 467'8. 

2G2 GEOOrvAPniCAL and historical rATnOLOGY. 

moisture. The first mentioned relation of tlic wind to the 
diffusion of the disease will be treated of subsequently. 
With regard to the other^ it has been shown by several 
observers, Koi'eff, Salvagnoli-Marchotti, Guislain, and others, 
that the fever in Sicily and on the mainland of Italy appears 
to increase both in severity and in amount during the 
prevalence of the African desert-wind or sirocco. It is an 
open question how far the " variations in the electrical 
tension of the air " caused by the sirocco come into the 
problem, as Marchetti contends that they do ; it is, at any 
rate, a less remote consideration to take into account, as 
pathogenic factors, the rise of temperature, and above all the 
increased amount of atmospheric moisture brought by that 
wind. The great importance, for the development of 
malaria on a suitable soil, of the compai^atively small precipi- 
tation caused by a heavy dew-fall, is clearly proved by the 
occurrence of the disease under those circumstances in 
districts where there is no rain, particularly on the coast of 

§ 6g. Altitude and Conpigueation op the Ground. 

The pronounced endemic character of malarial disease 
throughout so many large regions of the globe differing 
widely from one another in a great variety of circumstances, 
meteorological, anthropological, and social, justifies us in 
assuming at the outset that the occurrence of the disease is 
associated with certain conditions of the locality, and 
especially with conditions of the soil. There are, indeed, 
few points in the etiology upon which observers are so agreed, 
as that the soil has an influence in the production of malaria. 
But, as regards the actual pathogenic importance attaching 
to factors situated in the soil, as well as the way in which 
these factors help in the production of malaria, there are still 
wide differences between the views of the various investi- 
gators ; and it is only through a careful analysis of the facts 
that wo shall succeed in letting some light in upon this often 
explored, but still very obscure region of etiology. 

As regards the relation of the altitude and conf (juration of 



the ground to the oudemic and epidemic occurrence of 
malaria, the general law may be expressed by the formula, 
that the extent and severity of malarial diseases diminish in 
proportion as we ascend above the sea level. This relation 
is most marked in the diffusion of the disease in mountainous 
regions ; but it comes out unmistakeably also in a hilly 
country or among downs, as well as on a moderate declivity, 
or even on a level plateau with basin-like or cup -like 
depressions. It is always, ceteris i:)arilmSf the deepest points 
that are affected most by the disease ; the state of health is 
the more favorable the higher the locality. 

This fact in the distribution of the disease is illustrated 
on a largo scale in the valley of the Mississippi and upon its 
western declivity ; '' the constantly increasing elevation of 
the desert to the west of the Mississippi,^' says Drake,^ ''is, 
no doubt, one cause of the disappearance of the fever under 
the same parallels in which it prevails on the banks of that 
river." We meet with the same circumstances farther soutli 
on the slopes of the Rocky Mountains (Andes) of Texas 
{Br acid, Meyer), Mexico {Jourdanct, Liherman), Central 
America [Bernliard, v. Frantzius) and South America; also 
on the slopes of the Atlas in Algiers {Finot, Fliilippe), the 
table-land of Abyssinia {Harris, Gourhon), the elevated plain 
o£ Armenia {Wagner), the South German Alps, and the 
Apennines. Concerning the last-mentioned mountain chain 
within the (quondam) Kingdom of Naples, it is stated by 
Dorotea^ that malarial fever does not occur at all in the 
Alpine regions, i.e. at a height of 700 toises (1400 metres) 
and upwards, that in the Montana or cultivated zone (350 
toises and upwards) only the slight and simple fevers are 
observed in small numbers, while in the zone of the foot-hills 
the sickness begins to show itself more frequently, and the 
coast region forms its proper territory. To the same effect 
is the opinion of Salvaguoli-Marchetti on the distribution of 
the disease in Tuscan territory; in the mountainous and hilly 
country on the one hand, and the Maremma on the other. 
Even in the regions of most intense malaria, this influence of 
the elevation of the soil is unmistakeable. Thus, at many 
points on the West Coast of Africa, the disease becomes 
^ I, p. 715- ^ P. 181. 


rarer and milder the farther one goes from the level of the 
coast and the higher one rises {Ohificid, Ritchie, ITugtot); the 
heights surrounding Bussorah are almost free from malaria, 
whilst Bussorah itself is infested by fevers of tho worst 
kind (Hyslop) ; there is immunity also on the moderately 
elevated plateau of the Southern States of America. On 
a smaller scale this influence is shown in the endemic 
prevalence of malarial fevers, often within narrow limits, 
in low grounds, as in the central depression of tho 
country in Sweden, especially round the Lakes Malar and 
Wener, in tho Euglish county of Gloucester {Nash), in the 
district of Medoc {Lc Gcndrc, p. 13), and at innumerable 
points in the south-west of Gei*many.^ It is a universally 
recognised fact in malarial epidemics that, in districts with 
an undulating surface, tho deepest localities or portions of 
localities are attacked first and most severely. 

It stands to reason that the immunity of elevated regions 
from malarial disease is only a relative one, and this is 
explained by a consideration of tho conditions upon which it 
depends. On the one hand, the mean summer temperature 
is a determining factor ; the height to which malarial fever 
ascends at the various high-lying points on the globe is in 
definite ratio to the geographical position, and accordingly 
in an inverse ratio to the latitude of the place. 

In the alpine parts of Germany the limit of malarial fever may be 
j>laced at an elevation of from 400 to 500 metres, in Italy it rises to 
600 to 1000 metres, and to mncla the same LeigLt in the moiintaiuoas 
parts of Corsica {Gourmid, p. 29), on the slopes of the Atlas in Algiers 
{Leclerc, Armand (I) p. 125), and in the elevated mountain valleys of 
the Lebanon {Fmner). At still higher elevations (\ip to 2000 metres) 
we find malarial fever endemic on the slopes of the Himalaya and the 
high table-land of Ceylon (in the former at Kussali (Simla),'- and in 
the latter, at the same altitude, in Newera Ellia^), and in the form of 
"mountain fever" on the eastern slopes of the Rocky Mountains.'* In 
the Peruvian Andes the fever is met with at elevations even up to 

^ Sec the data given by Sclirudi-r as to the distribution of malaria in Sonth 

- Ireland, p. 21. 

"■ Tins statement, resting on the anthority of Marshall and Cameron, p. 'ji, 
has lately been confirmed by Massy (1. c, p. 497). 

•* Ewing, Hartbolow, Waggoner. Sec also the accounts given by Millian 
and Brewer for Utah Territory in the ' U. S. Army Reports/ i860, p. 304 ff. 


2500 metres or more, as in Tticna, according to Hamilton, and along, 
the mountain road as far as Arequipa. 

Tho second factor iu tins relative immunity oi^ elevated 
localities from malaria is imdoubtedly tho state of the soil 
as regards moisture, which is naturally different from the^ 
degree of moisture iu the plain. I shall recur to this cir- 
cumstance in the sequel ; I will only mention here, and 
merely by way of illustration, that wherever malarial fever 
is endemic at more or less considerable elevations, the seat of 
tho disease is always a valley with a small declivity, or a 
basin-liko depression in a plateau, while tho open levels, 
except so much of them as lie immediately at the foot of 
shelving mountain spurs, are, like the mountain ranges 
themselves, for the most part exempt.^ 

§ 70. Geological and Physical Ciiaeacteks op the 

Malarious Soil. 

The most important aspect of the origin of malaria is un- 
doubtedly that which presents itself in the question how far 
the disease depends, as an endemic or epidemic, upon the 
geological and pliysical conditions of the soil, upon the kind 
of rock, the porosity, the degree of saturation, the amount of 
organic detritus, and, further, upon the tillage, and perhaps,- 
also, upon the products resulting from cultivation. 

Whether geological characteristics of the soil exert an 
influence on the production of malaria is, to say the least, 
questionable ; at all events fhe opinions that have been put 
forward on that subject have not been accepted. 

Thus, Heine has been led to lay particular stress, from 
the pathogenetic point of view, upon tho amount of iron in 
the soil in the hilly fever-regions of the Deccan. On the 
other side, McClelland (p. 120) has shown that the laterite,^. 
to which Heine's suggestion refers, possesses all those phy- 
sical characters which are peculiar to malarious soil in 
general; and, conversely, we find the same formation of 

' The facts published by Steifensand, p. T15, on the prevalence of malarial 
fever iu the basin-like depressions amoug the mountains of the Lower Rhine 
are very instructing, on a small scale, for estimating these conditions. 


soil in many other districts adjoining tlio malarious localities, 
wliicli are tlieraselves free from malaria, sucli as Midnapur,^ 
Chota Nagpur, and Dornnda," as well as Simla and other points 
on the foot-hills of the Himalaya.^ In like manner we must 
reject, or at least receive with much caution, the notion, 
which I myself long shared, that a large quantity of salt in 
the soil, especially common salt and saltpetre, conduces 
materially to malarial fever ; this opinion is chiefly based 
upon the endemic prevalence of the disease on the west 
coast of Italy, on the table-land of New Castile, the steppes 
of Russia, the prairies of North America, &c.; but there are 
other regions, such as the pampas of the River Plate vStates, 
Avhich enjoy a remarkable exemption from malaria, although 
their soil contains the same ingredients. 

We may, in the meantime, safely limit the influence of the 
soil in the production of the malaria to its distinctive _^)/i7/.sica/ 
characters, among which the conformation and the kind of 
rock are certainly of real importance. But wo discovei', 
farther, that no formation and no kind of rock absolutely 
excludes the occurrence of malaria. It can be shown that 
the intensity of the morbific influence is materially increased 
by the porosity and hygroscopic character of the soil ; and 
accordingly the alluvial and diluvial formations are classical 
ground for malaria, while the older formations are more or 
less exempt in proportion to the compactness of the rock. 

The chief seat of the endemic malaria of the alluvium or 
diluvium is always found where there is a permeable and 
highly hygroscopic clay soil (clay, loam, clayey marl, marsh, 
&c.) ; a porous chalk soil is less favorable to it, and least 
favorable of all is a sandy soil. The relative exemption 
from the disease of the last mentioned kind of soil may be 
explained by reference to its distinctive physical characters ; 
readily open to saturation in consequence of its loose struc- 
ture, it is unable to retain the absorbed moisture, and it 
becomes dry almost as soon as it is saturated. It is only 
when a soil of porous chalk or a sandy soil rests upon highly 
hygroscopic clay, or a firm kind of rock, that the former are 
more apt to be associated with malaria ; the substratum is 
little adapted for conducting water, and the moisture that 
^ Goodcve (II). - Dunbar. ^ Ireland. 


lias sunk into tlio chalk or saud is unable to escape from 
them at once, and so this saturation is maintained for a 
considerable time. 

Linua)us was the first, as far as I know, who advanced 
the notion that malarial fevers were frequent on clay soil, 
on the strength of his observations in Sweden. The same 
fact has lately been demonstrated very conclusively by 
Meynne (p. 302) for Bclg-ium, and we find it to hold good 
for almost all the great malarious regions, and for the smaller 
spots of malaina no less, such as the marshy districts of 
England (Cambridgeshire, Lincolnshire, and Gloucestershire^) 
and the department of Calvados.^ The great liability to 
malarial fever of a clay soil, as contrasted with the exemp- 
tion of a sandy soil, comes out with especial prominence in 
all the epidemics that have occurred in the malarious regions 
of the North German plain and of the Netherlands. 

The exemption from malaria enjoyed by the islands of the 
"West Indies with a chalk soil, such as Barbadoes, is very 
remarkable when contrasted with the special prevalence of 
the disease in the islands of volcanic formation.^ In the 
sketch which Jourdanet (p. 150) gives of the malarious 
regions of Mexico, we read : '' In the towns of Campeche 
and Merida, both built upon chalk soil, intermittent fevers 
are not very common in comparison with other places,^^ and 
this statement is confirmed by Debout as far as relates to 

Concerning the distribution of malaria in Belgium, Meynne 
states (p. 307) : '^ It may be said in general that the strata 
of sand, permeable and containing very little of foreign sub- 
stances [viz. clay], are eminently healthy .^^ This exemption 
of sandy soil from malaria comes out prominently, as we 
have said, in the epidemic fever of the coast of Germany and 
the Netherlands ; thus Fricke, in his report upon the epi- 
demics of 1826 and 1827, states (p. 49) : '^ This form of 
disease showed itself in all localities which had the so-called 
clay soil ; from places with a sandy soil adjoining them, it 
was as if cut oif, although the latter were likewise affected 

^ Royston, Nash. 

* Account in the ' Lond. Med, and Phys. Journ.,' Ixvi, p. 87. 

3 'British Army Reports (West Indies),' 1838, pp. 26, 27. 


by the inundutions.'^ Further evidence of this occurs in the 
exemption of the sandy parts of Calvados as contrasted with 
the districts of that department that rest on clay ; McClel- 
land (p. 123) also states that the occasional spots, where there 
are interruptions of light sandy soil in the highly malarious 
lateritc (clay with iron) running through the South of Hin- 
dostan from Midnapur to Sumbulpur, are not subject to the 
endemic disease notwithstanding their immediate contiguity 
to the most intense malarious foci ; Lord says that in Lower 
Sind, which is notorious for its bad forms of malarial fever, 
the disease is rarely met with on a sandy soil ; and, lastly, it 
is observed by Annesley that the relatively favorable condi- 
tions of health at many points on the Malabar coast (Madras 
Presidency) are explained virtually by the sandy soil of the 

In complete agi'eement with the circumstances here spoken 
of, we have, finally, the fact that in localities which rest upon 
a rocky bottom, but are still the seat of endemic malarial 
fever, there is always a more or less thick layer of permeable 
alluvium, or diluvium, or mineral detritus spread over the 
firm rock, and always, therefore, a hygroscopic upper soil. 

We meet with malarial fevers under such circumstances 
on the rocky soil of Guernsey {HosHns), in Gibraltar, and 
in certain parts of Tennessee and Kentucky {DraJie) ; further,, 
on the greater part of the west coast of Italy, from the 
Tuscan Maremma down to Sicily, Avhere there is, resting 
upon the firm volcanic rock (basalt), a deposit of clayey marl 
of various thickness mixed with broken rock, and upon that 
again a stratum of the newest alluvium rich in salt (salmas- 
traje) ; again, in the Canary Islands {Lopez de Lima), where 
basalt or trachyte has volcanic tufa or clay resting upon 
it ; in Bcllary on the so-called " black cotton ground,^*' 
which is basalt covered with volcanic detritus -^ in Malwa, 
on trap with an upper stratum of sand (Ranken), and in 
Cutch [Winchester) ; and, finally, in the basins of the Tem- 
pisque and Rio Grande in Costa Rica, where, according to- 
V. Frantzius (p. 318), there is also volcanic tufa deposited^ 
on firm rock. 

^ Day, ' Indian Annals of Med.,' 1859, Jan., p. 86. 


§ 71. Saturation of the Soil. 

Under all these circumstances, then, the peculiar malaria- 
producing propei'ty of the soil seems to depend upon copious 
saturation of the ground and upon the concurrent formation of 
organic vegetable detritus. This saturation may be brought 
iibout by : 

(i) Atmospheric precipitations, the importance of which 
for the production of malaria has already been dwelt upon, 
while it has been at the same time proved that the intensity 
and amount of the disease not unfrequently stand in a direct 
ratio to their amount. 

(2) Nearness to larger or smaller basins, whose enclosing 
line is sufficiently low to prevent the drainage setting towards 
the more elevated rivers, lakes or pools ; so that the soil is 
constantly saturated, and the sub-soil water is high or low 
according to the amount flowing in, 

(3) Inundations occurring periodically or at irregular 

(4) Saturation of the ground with sub-soil water, a cir- 
cumstance which is calculated to throw light upon the occur- 
rence of malarial diseases in manv localities situated remote 
fi-om river basins, and whose soil cannot become saturated in 
other ways. 

The production of malaria takes place on the largest 
.scale under (2) and (3) of the above-mentioned conditions. 
Firstly, on the low coasts of tropical and subtropical 
countries, and on the damp, alluvial, and often flooded banks 
of their great rivers ; and in higher latitudes also, in many 
great foci of disease where the same peculiarities of the soil 
are recognisable, for example, the shores of the Caspian, the 
lower basin of the Volga, of the Danube, of the Rhine, of 
the Elbe, and of the Vistula. In the second place we find 
malaria exceedingly common in small and often definitely 
circumscribed spots by the sides of lakes, small streams or 
brooks, pools, ponds, and ditches, and extending just as far 
as the basin makes its influence felt in saturating the soil of 
the neighbourhood. There can be no well-founded doubt, 
therefore, about the intimate causal connexion between a wet 


soil and tlic production of tlic disease ; and the foniior may 
bo regarded as characteristic to some extent of malarious 
localities. A very striking example of this is furnished by 
the hygienic conditions in the Gironde, of which the follow- 
ing account is given by Ginti-ac : The department is divided 
by the Garonne into two almost equal parts^ a north-eastern 
with higher elevation and a thoroughly dry soil^ and a damp 
south-western division, the southern extension of which is 
the plain rising somewhat towards Landes, with the highly 
malarious Bordeaux at the northern apes of the triangle. 
Of 484 patients admitted for malarial fever into the Bordeaux 
hospital during four years, 105 came from the arrondisse- 
monts on the eastern bank of the Girondo, and 379 from 
those on the western ; but, inasmuch as the population of 
the first division was 254,150 and that of the second only 
179,429, the ratio of the sickness in the whole population 
was in the former case i in 2420 and in the latter i in 473. 

Besides these malai-ious regions, we have, thirdly, the 
endemic occurrence of the fever in localities that are 
periodically inundated by irrigation for the purposes of agri- 
culture. A classical example of this is found in the large 
malarious districts of countries where rice is much cultivated, 
as, for example, in many parts of India, especially the 
western division of Khandcish {Williamson I), in Java, in 
Ceylon {Gamero7i, p. 71), in Hong Kong [Wilson (I), p. 
147, Bill), and other parts of the south-west of China, in 
Japan {Wernicli), in Greece, in the rice-growing districts of 
Upper Italy [Ferraria, Savio, Maffoni), Sicily, and the north 
of France, in Portugal, and, in the Western Hemisphere, at 
Savannah (Georgia), where, according to Dauiell (I) malarial 
fever has become endemic since the rice-fields were laid out, 
and round about Charleston {Simons, p. 406), and at other 
places in the Southern States. In like manner, we may 
account for the prevalence of the disease in localities with 
extensive meadows and much cultivation of hemp (as in the 
low grounds of the provinces of Pincrolo, Saluzzo, Turin, 
Ivrea, and parts of the provinces of Asti and Alessandria in 
Upper Italy), in the mountain valleys of Syria in conse- 
quence of much garden-irrigation {Richardson), on the gold- 
fields of California, where the ground, originally dry, has 


been put under water for tlio purpose of gold-digging and 
agriculture {Logan), and under other conditions of a like 

Fourthly, and lastly, the importance of a wet soil for 
generating malaria is especially well shown in connexion 
with the endemic occurrence of malarial fevers in localities 
which, although remote from a river basin, have their soil 
abundantly saturated by subterraneous springs. Van 
Swieten was the first, and after him Pringle and Monro, to 
direct attention to this fact, and further inquiries in the 
various localities have afforded an interesting explanation of 
it. There are in Sicily, as Irvine (p. 5) states, many beds of 
streams which are quite dry in summer (the so-called 
fiumari), and malaria is endemic in their neighbourhood ; 
inquiry has shown that, in the bed of the stream higher up, 
there is a small rill of water which appears to sink suddenly 
into the sand, while in fact it pursues its way underneath 
the channel. This applies, for example, to the large fiumare 
running to the north of Messina, which appears to be quite 
dry in summer, but rapidly fills with fresh water if one digs 
not more than a foot or two ; " I have often observed,'' says 
Irvine, '^ that such fiumares as have, amongst the natives, 
the reputation of being subject to malaria, have streams of 
water running all the year in their superior parts.'' The 
case is probably the same with those seemingly dry malarious 
places in Sardinia, where the quivering of the ground under 
the foot (hence called " tremulo " by the natives) betrays the 
presence of sub-soil water. A further contribution to this 
subject is made by Celle fp. 10) with reference to the 
endemic occurrence of malarial fever at several places in 
North Africa : " There are " he says, " collections of subter- 
raneous water, arising cither from hidden sources, or owing 
their origin to the infiltration of rain water ; these collections 
rest always upon impermeable strata of argilaccous rock or 
marl, so that they have no other way of getting reduced 
except by the prolonged action of the sun on the surface. 
Not to mention the Sologne, there are certain parts of 
Algiers, of the coast of Tripolis and of Darfour, that are 
subject to the effects of these hidden deposits." Precisely 
the same explanation may be resorted to for the occurrence 


of malaria in several rainless oases of the Sahara, whose 
geological formation must be represented in some such way 
as follows : Basin-like depressions, of various extent, in a 
rocky or highly hygroscopic bottom, form i-eservoirs and 
channels for the collection of subterraneous water ; they are 
covered by a layer of alluvium, the sui'face soil of the oasis, 
and they swell in volume in spring in consequence of the 
snows melting on the interior mountain ranges of Central 
Africa. The influence of these subterranean collections of 
water upon the saturation of the soil above them is so great 
that, even in the intervals between the various oases, the 
sandy surface changes in spring into almost green meadows, 
affording a periodical sustenance to the cattle of the nomadic 
population of those regions. At several places, in Spain and 
Greece also, malaria is found, according to Armieux,^ under 
-the same circumstances. 

§ 72. Organic Matters in the Soil. 

The amount of organic matter in the ground is the last of 
those properties of the soil which we have found to stand in 
a causal relation to the origin of malaria. Observers at the 
most diverse points on the globe are nearly unanimous in 
saying that the development of the malarial poison depends 
directly or indirectly upon the processes of decomposition of 
organic and particularly of vegetable matters in or upon the 
soil, and that it is in a measure bound up with those pro- 
cesses. Drake (I, p. 709) sums up the American experience 
on this point with the words : " It is a safe generalisation to 
affirm that, all other circumstances being equal, autumnal 
fever prevails most where the amount of organic matter is 
greatest, and least where it is least. '^ We shall consider 
afterwards how far this opinion applies generally. 

§ 73. Changes in the Soil — Cultivation, Neglect op 
Cultivation, Excavations, Volcanic Disturbances. 

The experience of variations in the amount of sickness 
coincident with changes in the condition of the soil is 

' 'Gaz. dcs hopit.,' 1865, Sept. 


important as enabling us to estimate tlie influence of the 
soil on the production of malaria. There are here three 
main considerations : 

1. The decline or even the complete extinction of the 
endemic after the drying up of a previously damp or marshy 
soil, a fact which has been conclusively proved by observation 
hundreds of times in all parts of the world.^ 

2. The fact that, wJien the water is high and the ground 
completely covered hy it, the endemic or epidemic disappears, 
fresh cases of the disease appearing only after the water has 
run off and the surface of the ground has been laid bare. 
Classical examples of this are furnished by the malarious 
regions periodically inundated on the banks of the Nile, 
Indus, Euphrates, Ganges, Senegal, Niger, Mississippi, and 
other rivers, where the endemic always begins after the 
waters have begun to subside. There is another illustration 
of the fact in those rice-fields in India which are always 
under water, and, as Annesley remarks, are the least 
dangerous to health. Experience also in Turkey [8 and with) , 
in Sardinia {Moris), at several places in the Southern States 
of the Union {Nott), in England (Royston) and elsewhere, 
proves that the complete flooding of marshy ground, and 
the filling up of standing pools, ditches, and the like causes 
the endemic to disappear as certainly as if they had been 
dried up. 

3. The way in which the soil is treated has an influence 

upon the amount of sickness. Thus the breaking up of 

virgin soil and other operations of that kind, the cutting 

down of woods, and the neglect to cultivate ground that 

used to be tilled, are favorable to the occurrence and 

prevalence of malarial disease ; while, on the other hand, a 

' Meynne (p. 286) writes thus of the improvement in the sanitary conditions 
of Belgium : " The progressive diminution of endemic interraittents in the 
coast belt is an ascertained fact, and that diminution has everywhere coincided 
■with the disappearance of marshes, the extension of cultivation, and the esta- 
blishment of a regular system of storing water." The same applies equally to 
many localities where these principles are carried out on a large or small scale, 
particularly to the notorious malarious districts of France, the Sologne, the 
Dordogne (Sclafer), and the like, where there has been a considerable decline in 
the sickness since the amelioration of the soil was undertaken; many districts 
in them, which used to be almost uninhabitable on account of malaria, now 
enjoy the most favorable sanitary conditions. 



careful and regular cultivation of the soil contril^ntos materi- 
ally to improve tlio liealtli of a locality. 

The development of malai'ious foci in consequence of the 
reclaiming of the soil, and the disappearance of the disease 
after its complete cultivation, arc facts that have been 
observed on a grand scale in the most diverse parts of North 
America. " It is a well-known fact/^ says Rush (p. 97), 
''that intermittent and bilious fevers have increased in Penn- 
sylvania in proportion as the country has been cleared of its 
wood, in many parts of the State. It is equally certain that 
these fevers have lessened or disappeared in proportion as 
the country has been cultivated." Similar observations have 
been made in that State more recently, as in 1 849 in Bradford 
County, where there was an increase of malarial fever in 
consequence of the reclaiming of a large tract of land.^ 
Statements to the same effect have been published also by 
Collins, Gibbs, and others for the Gulf States ; by Williamson 
for North Carolina ; by Somervail for Essex County, South 
Carolina, and by others. The most recent experiences, and 
those on the largest scale, come, as might be expected, from 
the Western States ; they include those of Gairdncr for 
Astoria, and of Keenay, who gives an account of the appear- 
ance of malarial fever under the above-mentioned conditions 
at the several military posts in Iowa," and adds : " The fact 
not only holds good here, but has generally been so at all 
the various stations at which I have been, particularly at 
those posts where the cultivation of the soil has been one 
of the duties of the command ; " of Logan for California, and 
of Stratton for Canada, where, as he states in his report, 
the diffusion of malarial fever has followed the progress of 
immigration and reclaiming of the soil from east to west, 
while the disease has diminished also in proportion as the 
country has been brought more completely under cultivation. 
As to the influence of the breaking up of virgin soil, there 
are numerous observations from Brazil {LaUcmant, Aschcn- 
feldt), from Algiers since the occupation of the country by 
the French {Bcaumez, Jacquot (I), p. 610), from Egypt, 
Asia Minor, and Syria {Primer, pp. 356-359), from Java 

' Account in the ' Transact, of the Pennsylvania State Med. See.,' 1859. 
= ' U. S. Army Keports,' 1856, p. 53. 


{Sivavhui) , and from tlie Banat [Weinherger) . The remark- 
able increase Avhicli has occurred in the pernicious remittent 
fevers {fehris rcmittcns hmnoi-rliagica) within the last ten or 
twenty years in the Southern States of the Union is referred 
to by Norcom as follows : " Before the war, the Southern 
States were in a high state of cultivation and the lands 
thoroughly drained; hence the malignant forms of malarial 
disease as a general rule were not known, except in very low, 
badly-drained, swamp lands. Within the past eight years 
[written in 1 874] , owing to so much land lying waste, defective 
drainage, and the general unsanitary condition of the country, 
the malarial poison has acted with intense virulence, and 
caused the disease we are now considering.^' The same 
opinion is expressed by Green, by observers in Georgia, and 
by others. 

Another interesting example of the appearance of malarial 
disease in consequence of deterioration of the soil in localities 
hitherto exempt from them, is furnished by the East African 
islands of Mauritius and Reunion. The fever has been observed 
in them since 1 866, but all the authorities agree in stating that 
the two colonies had enjoyed a remarkable immunity from 
malaria up to that year. The coast and the level country of 
the Mauritius, which formerly afforded a rich soil for the 
growing of coffee, indigo, and cotton, had been gradually 
allowed to go out of cultivation and had become entirely 
baiTcn ; it thus became necessary to go higher for fruitful 
tracts of land to bring under cultivation, and the result has 
been the laying out of the sugar plantations, which have proved 
highly remunerative. But the deforestation rendered neces- 
sary by this new industry has led to a material change in the 
hydrology of the country ; the mountain torrents that used 
to carry a great volume of water down to the coast, have 
either disappeared altogether or they have become so small 
that they scarcely reach the shore in their course, often 
sinking into the ground or forming small standing marshes. 
Then, in 1865, there came excessively heavy rains, which 
contributed still more to the formation of marshes ; and thus 
there developed in 1866, under the influence of very high 
temperature, an epidemic of malaria which quickly spread 
over the whole island, and appears to have left the disease 


endemic behind it. All this applies equally, as Lacaze states, 
to Reunion, which has always omulnted the sister island in 
its plantations, industries, and trade. ^ 

There is a scarcely less voluminous body of experience- 
going to prove the influence upon outbreaks, or exacerbations 
of the disease, which has been exerted by excavations involving 
the disturbance of the soil to a considerable depth, such as 
trenches, canals, dykes, railroads, and liighways, particularly 
when such works have been carried out on a malarious soil.^ 
Improvement in the sanitary conditions of a locality by regular 
cultivation of the soil (whereby there are not only largo 
quantities of water withdrawn from it, but perhaps also the 
processes of decomposition taking place in it are modified)- 
has been demonstrated in various parts of the globe by the 
results that have followed the planting (undertaken with 
that object) of a highly absorbent vegetation. The first 
attempt of the kind, so far as I know, was the planting 
of the sunflower [JleUantlms annnus) in the malarious 
neighbourhood of Washington ; according to the account 
of Maury the effect has been very advantageous, and the- 
same good result has been attained, as Martin^ states, in 
some parts of the Netherlands. Experiments on a still 
larger scale, and attended by the same success, have 
been made with plantations of Eucalyptus globulus. The 
English were the first to plant that tree, at the Cape, for 
the purpose of drying the soil ; the practice was afterwards 
carried out, as a sanitary measure, in several of the most 
malarious parts of Algiers, and, as Gimbert assures us, with' 
equally brilliant success.'* Summing up all these expe- 

' See also the accounts bj- Barat, Nicolas, Barraut, Mercurin, Tesslcr,. 
Bassignot, and Lacaze. 

* Very interesting observations have latclj' (1868-70) been uaade on this point,, 
according to the statement of Fokker, among the workmen employed in making 
the camds in Walchcren. 

3 ' Revue de therapeutique,* 1867, Nov., p. 15. 

'' The 'Gazette hebdomad, de I\lixl.,' whi^h publishes the second report of 
Gimbert, adds the following editorial note (1875, p. 341): — " W'^c have our- 
selves had occasion to verify these properties. At the approach to the bridge of 
Var, on the railway, there is a guard-honse built on alluvial deposits, which has 
been infested by intermittent maish fever. Every now and then it became- 
necessary to change the occupants of it. Struck by these results, M. Villard 
got the idea of surrounding the house with eucalyptus. Since the first year 
after that was done the fever has completely disappeared." 


riences, Day remarks that the prevalence of malarial disease 
" is lessened by cultivation^ increased by depopulation,^' and 
Aschenfeldt says : '' Nothing but the greatest wildnoss or 
perfect cultivation protects a region from malarial fever/' 

Finally, I must here direct attention to the singular fact, 
often observed, that changes in the soil brought about by 
volcanic disturbances have repeatedly led to an outbreak of 
malarial disease or to a considerable increase of it. The 
first observations on this subject come from Italy — from 
Rome in 1703 {Baglivi, pp. 51, 388, 566), from Reggio in 
1783 {Mammi), and from Palermo in 1828 {Merlctta). In 
Peru, also, according to Smith (II) and Tschudi (pp. 440, 
469) a remarkable increase of the disease has been noted 
after earthquakes. In recent times there has been a 
striking illustration of the same fact in Amboina [East 
Indies] ; Epp, Heymann, v. Hattem and Popp, agree in 
stating that the island up to 1835 was subject only to a 
moderate amount of malarial fever of the simpler kinds, but 
since the earthquakes that took place in that year, the dis- 
ease has undergone a steady increase, both in its area and 
its intensity. 

§ 74. Exceptions to the Rule that Makshy Soils are 


There are few points in the etiology of disease about 
which so complete an agreement exists among observers, 
as the significance to be ascribed to the agency of the above- 
mentioned factors in the production of malarial diseases ; the 
state of the case appears in fact to be so clear that it must 
impress the observer almost without being formally stated. 
The close association of malaria with a particular kind of 
soil, highly saturated and rich in organic matters, especially 
vegetable matters, and the fact that the disease breaks out 
whenever that kind of soil is subjected to a high temperature, 
suggests the conclusion that the development of the morbid 
poison goes hand in hand with the processes of decomposi- 
tion set up in organic matters under those circumstances. 
This opinion will find all the readier acceptance the more 


one attends to the fact that tlio malady prevails most on 
the particular soil that has all these characters most pro- 
nounced, viz. marshij ground, and in those tropical and sub- 
tropical regions whore the processes of decomposition are 
most active under the influence of very great heat. It will 
gain in probability, also, the more one is led to admit the 
effect on the amount of sickness produced by those changes 
in the condition of the soil and climate of which we have 
been speaking (§ 73). However much there may be in this 
view that is undoubtedly correct, it has in the end led to a 
one-sided ; theory and the theory having degenerated into a 
dogma, the effect has been rather to obscure than to elucidate. 
The facts that I am about to state will, in my judgment, 
serve to prove, on the one hand, that all those conditions in 
the soil and in the atmosphere which are required to account 
for malaria according to the sivamp theory — if I may be 
allowed the expression — do by no means sufiicc of them- 
selves to bring about the disease ; Avhile, on the other hand, 
the facts in the sequel serve to prove that the disease occurs 
both endemically and epidemically very frequently under 
circumstances where the effect of a saturated alluvial soil 
exposed to a high temperature is altogether excluded, or 
where the states of the soil, and the meteorological states, 
correspond so little to those demanded by the theory, or 
differ so little from the telluric and climatic conditions at 
innumerable other and non-malarious places, that it is impos- 
sible for us to find the cause of endemic or epidemic malaria 
in then; alone. 

Instances of non-malarious marsh. — One of the most in- 
teresting, although hitherto least noticed, phenomena in the 
history of the malarial diseases is j)reseuted to us in the 
excm^jtion enjoyed by many large tracts of country, espe- 
cially in the Southern Hemisphere, whose circumstances of 
soil and climate would lead one, on the analogy of other 
regions much subject to the malady, to expect its endemic 
occurrence. I shall limit myself to a few of the most 
striking facts relating hereto. 

In tlie first edition of tliis work (I, p. 56) I Lad already called atten- 
tion, althougli with some reserve, to the fact, voaclied for by Wilsou 
and Bniuel, that the pauijias of the River Plate Statea were quite free 


from tliis disease, notwitlistanding tlieir resemblance in geological 
features to the prairies of North America and the savannas of Brazil, as 
well as their situation in comparatively low latitudes — notwithstanding, 
in short, that they afforded all the conditions necessary for the pre- 
valence of malaria. I am now able to prove this assertion by the most 
certain evidence, so that there cannot well be any doubt about the fact 
itself. Mantcgazza (I, p. lOo) says, with reference to the banks of the 
Rio de la Plata : " Paludal fevers are nowhere known ;" and he adds (p. 
2S6), concerning the sanitary conditions in Paraguay : " Intermittent 
fevers have not that gravity that one might expect in such a latitude 
and amidst so much moisture." On this point Dupont is explicit (p. 
13) :" Intermittent fevei's are entirely unknown along the littoral (of 
the La Plata) ; it is difficult to say to what cause their absence is to 
be attributed, but all physicians are agreed that they are absent. . . 
. . The country presents, at any rate, all the geological conditions 
suitable for the development of malarial fevers — undulations of the 
surface hardly perceptible, periodical inundations over vast tracts of 
land, marshes and lagoons of great extent along the banks of the 
rivers, great elevation of the temperature in summer." To the same 
j)urport is the statement of Bouffier: "The numerous islands of the 
Parana are covered with innumerable marshes, which fill and emytj 
with the rising and falling of the river. Those marshes contain an 
enormous quantity of debris, both vegetable and animal ; the bottom is 
generally muddy. As soon as the level of the river falls, an immense 
extent of marshy ground becomes exposed. For all that, I have not 
observed a single case of intermittent fever, and, from the information 
that I have been able to gather, it appears that this affection is rare 
among the indigenous inhabitants." Humboldt had already pointed 
out that the marshy banks of the Amazon in the upper part of its 
course are almost free from malaria, in contrast to the banks of the 
Orinoco and Magdalena ; and that statement has been confirmed by 
Bates, one of the most recent and most trustworthy travellers in those 
parts, as well as by Gait (I). On the Peruvian pampas, also, in the 
upper valley of the Sacramento, malarial fever appears, from the 
experience of Gait (II) to be very rare. Of the montana region of that 
country Tschudi (j). 440) remarks : " AVe again come upon valleys with a 
rich vegetation, with a muggy and hot atmosphere, and covered with 
marshes, in which the disease is quite unknown." If we turn, now, in 
this survey to the eastern part of the Soiithern Hemisj)here, we find in 
Australia and Polynesia a region almost absolutely free from malaria, 
notwithstanding that the climatic and tellm-ic conditions, which have 
been frequently mentioned as favorable to the production of the moi'bid 
poison, are j)resent there to the fullest extent. As to the complete 
exemj)tion from malaria enjoyed by Van Diemen's Land and New 
Zealand, the opinions of Dempster (I, p. 355) and Scott agree with those 
of Johnson and Thomson. It is more especially pointed out by the 
last-mentioned writer that Europeans who have lived for years in New 
Zealand on the alluvial banks of the Waipa and Waikato hiivc 


remained tiuite free from fever, and that others who have come to New 
Zeahind in ill health from nudarious countries in the tropics have com- 
pletely recovered. I have already given (p. 209) more particular 
details of the proportion of sickness among the English troops in that 
colony, and of the non-malarious condition of many of the groups of 
islands in Polynesia. The immiiuity from malaria which New Caledonia 
enjoys has excited the greatest astonishment among the French physi- 
cians; notwithstanding an alluvial soil abundantly saturated and covered 
with luxuriant vegetation, says De Rochas (p. 15), and in spite of an 
almost tropical climate — the mean temperature of the year amounting to 
22° — 23° C. (71° — 73° Fahr.), and the mean summer temperature to about 
26° C. (79° Fahi'.) — malarial fever is almost unknown there; and, in 
fact, he saw during three years only a single case (of intermittent facial 
neuralgia) among a body of troops averaging from 90 to 100 strong, 
who employed themselves in road-making, trenching the ground with a 
view to its cultivation, hunting in the marshes, &c., without taking any 
precautions. Charlopin (p. 16) says that "the grand fact, which at 
once strikes the physician, in the pathology of New Caledonia, is the 
absence of intermittent fever, notwithstanding that all the conditions 
favorable to the existence of that malady are brought together at 
various parts of the island, and especially at the points most inhabited." 
To the same eifect Bourgarel (p. 344) states : " I do not know that there 
has been a single case of intermittent fever, in spite of the vast marshes 
that are met with at the mouths of the numerous streams which water 
the island." Nor are striking examjilcs of the same kind wanting in 
the tropical regions of the Northern Hemisphere. Thus Taulier 
remai'ks that in Manilla malarial fever has a very mild type, although 
the town is built upon a damp soil and surrounded by marshes and 
rice-fields; and Macculloch, speaking of the exemption of Singapore 
from malaria, says : " There is a mystery for which I can conjecture no 
solution, while every imaginable circumstance is present to render the 
land in question one of the most pestiferous spots under the sun ; it is 
a collection of jungles and woods, marshes and rivers, and sea swamps, 
and it is a flat land under a tropical sun, and it is the land of monsoons, 
and yet it is a land where fevers are unknown ;" and this assertion is 
confirmed in the details given by McLeod as well as in the official 
reports.' In the same way as the French physicians speak of New 
Caledonia, the English observers express their astonishment at the 
complete absence of malarial fever in the Bermudas ; in the first official 
report, relating to the period from iSi7to 1836, we read i'^ "It is especially 
worthv of remark that, notwithstanding the numerous marshy situations 
in different parts of the island, fevers of the intermittent type are almost 
altogether unknown." During the twenty years referred to, there were 
only 27 cases in a total of 15,356 men ; and, according to the report for 
the twenty years following,^ there were 25 cases among 11,224 men, of 
1 'Madras Quart. Journ. of Med.,' 1839, i, p. 64. 
* 'British Army Reports,' 1839, 6J. 
3 lb., 1853, p. 176. 


wliicb about one lialf occurred iu 1840, and these had been imported 
from the West Indies. The most recent account by Tucker entirely 
confirms this : " As a further proof of the marshes being innocuous, 
marsh or intermittent fever is unknown on the islands, which would 
not be the case otherwise. And, moreover, persons who have con- 
tracted fever and ague abroad often resort to this climate as a restora- 
tive." Undoubted evidence that the same circumstances occur also in 
higher latitudes is furnished from numerous marshy regions of North 
America, from Ireland,' which is quite free from fever in spite of its 
bogs, and from many parts of Sweden.^ 

§ 75. Malaria in Dry Places^ Anomalous Exacerbations, 
Epidemics and Pandemics. 

Iu order to estimate tlie importance that we sliould assign 
to wet soil, organic detritus, and such like etiological factors 
in the production of malaria, it is hardly less necessary to 
keep in view the endemic occurrence of the disease, and 
even of severe forms of it, in regions whose soil, in so far as 
relates to degree of saturation, hygroscopic properties, and 
richness or poverty of organic matters, does not diifer essen- 
tially from the soil of many other places, sometimes in the 
same neighbourhood, which are cither altogether free from 
malaria or only slightly affected by it. Classical examples 
of this are afforded by the hill- fever on the tableland of the 
Deccan, by the prevalence of severe malarial fever at a few 
mountainous points of Peru, by the so-called mountain fever on 
the slopes of the Rocky Mountains in North America, and 
by the endemic malaria on the west coast of Italy, especially 
in the Tuscan Maremma and the Roman Campagna. 

"There are two errors," says Colin (p. 34), "which usually enter into 
the opinion that one forms of the Roman Campagna ; some regard it 
as barren and unfruitful, others think of it as covered with stagnant 
■water or marshes. To be disabused of the notion that it is barren, we 
have only to appeal to the I'cminiscences of those who have travelled 
through that country either iu spring or in autumn. . . . Again, 
in numerous journeys made through the Agro Romano, we have become 

1 Oldham remarks that this exemption of Ireland from malarial fever in spite 
of the extensive tracts of marshy laud " has long been a puzzle to writers ou 
p:iludal poison." 

' Burgman, p. 250. As examples he gives the country around the lakes in 
Gstergotland, Upland, Sodermanland and Nerike. 


convinced, ultliongh to our great surprise, not only that there are no 
marshes, but also that the soil is of extreme dryness." And there can he 
equally little talk of marshy soil in the Tuscan Maremma. The regions 
of the so-called " hill-fever" of the Deccan, the tahlelands of Malwa, 
Ohota Nagpur, and Mysore ai'c in like manner described by observers ' 
not only as free from marsh but as comparatively dry. The soil 
belongs mostly to the trap formation, deposited in the form of broken 
rock upon a granite bottom, and it contains, besides various ingredieut.s 
such as quartz and felspar, a jjreponderant amount of ferruginous 
chalk. In Chota Nagpur, the soil is so porous that it becomes 
absolutely dry a few hours after the heaviest rain ; and many of the 
worst fever-spots of Mysore are situated on so steep hill-sides that the 
water which has fallen runs olf with great rapidity in cascades, the 
soil requiring to be irrigated artificially, and being extremely difficult to 
irrigate. It is obvious that no rich vegetation is to be met with in 
those regions. These conditions stand out still more prominently 
where malaria is prevalent on the bald, arid, and sterile tableland of 
New Castile, one of the most rainless steppes in Europe, Avhose scanty 
cultivation is kept up mostly by artificial irrigation ; and, again, upon 
the tableland of Iran, which lies always under a cloudless sky and 
bright sun, and has no water from natural sources ; and, further, on the 
plain of the Araxes, and elsewhere. 

Another very notewortliy plienomenon in tlie history of 
malarial diseases, arising in this connexion, comes out in 
the above-mentioned fluctuations in the amount, and change 
in the character of the disease, in districts where malaria is 
endemic ; and in the establishment of new malarial foci, wliich 
we can explain neither by changes in the soil nor by definite 
conditions of weather. 

The siidden appearance of pei-nicious malarial fever in many parts 
of Chili subsequent to 1851 is an interesting exauiple of this (see 
p. 222). In speaking of the endemic malarial fever at Opelousas, Cooke 
says (II) : " The country has often enjoyed most excellent health, in 
spite of great and continued heats, excessive rains, and east winds, 
while in other years, under the same circumstances, it has been severely 
visited by the disease. On the other hand, there have been years in 
which one seemed justified in counting on a good state of health, from 
the mild temperature, the steady weather, scanty rainfall, and the like, 
bu.t in which the disease has been very Avidely spread. No one in thin 
country is in a position, from liis ohservdtions and tw.jicricnce, to name the 
circumstances which exert an unfailing ivflttence upon the production or 
even the exacerhution of malarial disease." Precisely to the same effect is 
the opinion of Boling with reference to the periodical prevalence and 
subsidence of the disease in Alabama, and of many observers in Pennsyl- 

1 Sec the accounts by Rauken, Goodeve, Dunbar, uiul, hi particular, lleyue. 


vania, New Yoi-k, Indiana, New Jersey, and other parts of North 
America. Fricdlieb' infers, from observations made during a long 
series of years in Dittmarsehen, that " ague may originate and become 
epidemic without the influence of marshy exhalations, and in all 
kinds of weather, and may fail to break out in marshy districts at 
times when the swamp atmosphere is developed to the highest degree." 
From similar experiences collected in Rochefort, Lucadou concludes 
(p. 7) : " It is impossible to regard the exhalations of the marshes and 
the various constitutions of the atmosphere as the sole causes of the 
autumn sickness." Cameron says of the malarial fever of Ceylon 
(p. 72) : " Certain years prove much more sickly than others, without 
any very evident cause." 

But all attempt at explanation^ iu the above sense, is 
baflfled by the outbreak and epidemic prevalence of the 
disease in those regions which, spared as they are from 
endemic malarial diseases, offer nothing in the conditions of 
their soil that seems able to further the production of 
malaria ; and we are baffled still more by those pandemic 
outbreaks of malaria which attain a wade diffusion over great 
tracts of country and whole regions of the globe, and run 
their course, not within one season nor even within one year, 
but often last for several years, and then remain absent for 
years or tens of year^. 

I shall select from the overwhelming mass of facts relating to this 
point, two observations only, belonging to one of the latest pandemics 
(1858 to i860). In his account of the circumstances of the disease in 
Filrth during the years 1859-60, Frohmuller^ remarks: "Our special 
attention was attracted this time to ague, which broke out to an 

extent hitherto unknown in Fiirth Moreover, the general 

situation of Flirth is such that epidemics of ague had not previously 
been able to reach it; the elevated" position of the town, between two 
river vaUeys, allows the water to run off quickly, and the Keuperbed on 
which the town stands, favours rapid absorption. Neither marshes nor 
stagnant waters lie around the town. . . . The damj) character of 
the summer might well have acted as an encouragement, but we have 
often had damp summers without having had ague. A siiecial factor must 
therefore be assumed, which it is impossible for the present to specify." 
Of the same pandemic, Camerer states, with reference to the disease in 
Stuttgart and other parts of Wiirtemberg that are absolutely exempt 
from endemic malaria ■} " Inasmuch as ague began to be more frequent 
even in the hot and dry sum mer of 1 859, it cannot be laid solely to the 

^ 'Hamb. Mag. fiir die ges. Heilkile.,' 1830, xix, p. 209. 

* 'Bayr. arztl.-Intellgzbl.,' 1861, p. 45. 

3 * Wiirttemb. med. Correspondenzbl.,' 1861, p. 92. 


•account of the cold and wet of last year (iS6o), altliougli the weather 
of that year may certainly have contributed its OAvn share to the 
diffusion of the intermittent fever. Cn the whole, there must have 
been other and unknown factors contributing to bring about this form 
of disease." 

§ 76. Ship Malaria. 

Joining on to this group of facts, tlierc is finally the 
■epidemic occurrence of malarial fever among the crews of 
ships on the high seas, which cannot be referred to a previous 
infection of individuals on shore, but where we have to deal 
with true " ship-malaria " (Fonssagrives) } There have been 
doubtless many observations counted among these by mistake, 
in which the reception of the morbid poison by the patient had 
taken place ashore, the incubation having lasted for several 
weeks, as experience has not rarely shown that it may 
last. In going through the literature before me, I have 
therefore eliminated carefully all those records in which it was 
certain or at least probable that the disease had been acquired 
on land, or in which there was any sort of doubt as to the 
origin of the disease ; and I adduce from what remain the 
following observations on " ship-malaria " which seem to me 
to be especially convincing. 

On board a ship of war on a voyage from France to the Cape, an 
<3pidemic of malignant malarial fever broke out, according to the account 
of Laure (II, p. 12), just after the vessel crossed the line ; the ports had 
not been open for fourteen days in consequence of very stormy weather, 
and the ship had become everywhere very wet owing to the open- 
ness of her planking. In this case a previous infection of the crew 
could be excluded with certainty. Under the same circumstances, 
according to Bonnaud, an epidemic of malarial fever broke out during 
a voyage from Toulon to Podhor, on board a very crowded frigate 
which had been lying for several years at Toulon and had had her 
bilge-water imperfectly pumped out ; the crew, who had not come from 
malarious localities, continued to be affected for three weeks, when 
better weather set in and a sufficient ventilation of the hold and 'tween 
decks became possible. Marston- gives an account of an outbreak of 
malarial fever on board a ship bound for England from a Baltic port 
Avith a cargo of wet deals, the whole ship's company falling sick, from 
captain to cabin-boy; here also an infection of the individuals ashore 

1 < 

2 < 

Tniitc d'hyp:. uaviilc,' Taris, 1856, p. 218, 
Ediu. Mud. Jouru.,' 1862, i-'ub., p. 709. 


was certainly excluded. The following account by Holden,^ of an 
epidemic of malaria on board a United Status' ship of war, is especially 
interesting. After leaving tbc port of Norfolk (Va.), a pestilentia-l 
stench from the bilge-water spread through the lower hold ; no cases 
of sickness occurred among the crew, although some of them had to 
frequently enter the part of the hold containing the ship's stores, 
situated under the great cabin. A short time after, it became necessary 
to visit another store-room in the immediate neighbourhood of the 
bilge space, when the person who was sent found everything in it 
covered with mould. On the afternoon of the same day that person 
sickened with ague, and in the days following, more sickness occurred, 
but only in those who had entered the part of the hold which was still 
kept closed. The ship having put in to Beaufort, the bilges were 
cleaned out, and so long as the store-rooms were kept open, there was 
no fresh sickness ; but when this regulation was afterwards disregarded, 
new cases showed themselves, but only among those — including Sur- 
geon Holden himself— who had entered the room covered with moulds 
Facts quite similar to these are given by De Lajartre (p. 20), as 
observed by himself and Mairct, and by Siciliano. In the case reported 
by the latter, it was a Fi-ench ship of war carrying troops and convicts 
from Toulon to Guiana and the West Indies. Here, again, the ports 
had to be closed in consequence of bad weather, so that the lower gun- 
deck could not be ventilated ; and the impure state of the air in it was 
aggi-avated by a frightful stench spreading from the bilges, the gun- 
deck being all the while crowdi;d -svith men. The first cases of malarial 
fever occun-ed as early as the second day out, and the epidemic did not 
cease until the bilges had been thoroughly cleaned. Something over 
sixty persons in all took ill, but they were almost exclusively those who 
were quartered in the after part of the lower gun-deck (oflficers, cadets, 
servants, &c.) ; while only isolated cases of sickness occurred among 
those occupying the upper gun-deck (passengers, convicts). 

Impartial criticism cannot but conclude from all the facts 
above stated, that a saturated alluvial or marshy soil becomes^ 
under the influence of high temperature, a very essential 
factor in the production of malaria. But at the same time 
malaria is not absolutely bound up with that etiological 
factor, as a necessary result of its activity. There is some- 
thing more to be postulated, whether it be in or upon the 
ground or floating in the air, a sijccific lootenttalUy which 
furnishes the real condition for the development of malaria, 
a potentiality that springs into being most easily and grows 
most luxuriantly under the influence of these etiological 
factors. But this potentiality may develop under other suit- 
able circumstances, and quite independently of the former. 
' ' Amer. Journ. of Med. Sc.,' 1866, Jan., p. 77. 

28G nEorjRAT'riiCAL anp piistorical pathology. 

§ 77. Necessary to assume a Specific Poisonous Substance. 

Search for Germs. 

'^'^ Without the assumption of a material and specific 
malarial poison," says Griesinger very justly, '^we shall not 
proceed far in explaining the enderaicity of the fever." 
This declaration is primarily directed against the assumption 
of those observers who think themselves justified in referring 
tJie origin of the sickness to weather influences alone, to great 
diurnal range of temperature, especially when the days are 
very hot, the nights cool, and the air highly charged with 
moisture. If this theory, which was started by Maillot, 
Faure, Folchi, and others among the older observers, finds 
partisans at the present day in Espanet, Arraaud, Philippe, 
Burdel, Meyersohn, Kostler, Minzi,^ Black, Ridreau," Weir, 
Oldham,'^ Munro, Morrison, and others, the favour that it 
still finds is explained by the fact that the efforts of the 
former generation of observers, to bring the facts into 
harmony with the one-sided marsh-theory, wore futile. 

All the arguments of this school are directed against the 
marsh-theory ; and, having represented it as an erroneous one, 
they not only make the mistake of ignoring what there is of 
right in it, but they come themselves to a conclusion which 
goes far beyond the doctrine of the marsh-theorists in its one- 
sidedness and its palpable errors. I hold the specific nature 
of malarial disease to be so generally admitted, and the 
belief in a specific cause underlying it to be so little open to 
challenge, that I do not think it necessary to enter further 
on a criticism of this catching-cold theoiy, if I may be 
allowed so to name it. 

All that we Icnow of the production of malaria forces us to 
assume that it stands in a close connexion with the pro- 
cesses of decomposition of organic matters, especially vege- 
table matters ; and, inasmuch as the soil chiefly furnishes 
tliose matters and principally aids their decomposition, we 

' 'Sofra la gcnese delle febrl intennittcuti,' Roma, 1844. 
^ 'Rcc. (l(! incm. de mod. milit.,' 1868, Oct., j). 289. 

^ ' What is Malaria ? and Wliy is it most intense iu Hot Climates ?' London, 


are led to assume tliat malaria is bound up with tlic soil in 
an essential degree, if not altogether unconditionally. In all 
decomposition (rot or putrefaction), so far at least as relates 
to extrinsic activity, two factoi's come into account : the pro- 
ducts of decomposition, which are cither gaseous or solid 
matters, and the excitants of decomposition whoso organised 
nature cannot well be longer doubted. CoiTosponding to 
these assumptions, there have been certain theories hitherto 
current as to the nature of the malarial substance. One view 
is, that it is represented by a kind of gas or gaseous mixture ; 
the other view runs into the zymotic theory, on the one hand, 
and the parasitic theory on the other. 

The first-named and oldest of these, already hinted at by 
Varro,^ afterwards laid down by Lancisi,^ extended by 
Baumes^, and adopted by Savi, Dauiell, and Boussingault, has 
found a few adherents even in the most recent times. It is 
based upon the detection of hydrogen compounds of sulphur 
and carbon in the air of the marsh, and particularly upon the 
fact tliat volcanic soil is a favourite seat of malarial foci, and 
that the disease occurs so frequently in the very neighbour- 
hood of active volcanoes. This theory has lately been 
adopted by Schwalbe, who explains the malarial poison to be 
carbonic oxysulphido, according to his observations made in 
Central America. He assures us that carbonic oxysulphide 
may be detected by the smell on the Isthmus of Panama ; 
but he adds that the experiments which he has made upon 
animals with that gaseous mixture have not given a positive 
result, and that there are perhaps still other gases or gaseous 
mixtures in which the cause of the disease might be found. 
Against this theory, there is the fact that the effects of the 
different gaseous combinations are well known, and that 
none of these effects correspond to the peculiar phenomena 
of malarial sickness. Further, it is certain from the 

I ' De Architectura,' lib. i : " Spiritusque bestiarum palustrium veuonatos, cum 
nebula laixtos, iu habitatorum corpora flatus spargcnt, efficinnt locum pcstilen- 
tem." It is certainly doubtful whether Varro here implies by the word " spiritus," 
the breath of poisonous animals or a development of poisonous kinds of air from 
the decomposition of the latter. 

^ *De noxiis paludum efHuviis,' &c., Colon,' 1718. 

3 ' Mem. sur les maladies qui resultent des emanations des eanx stagnantes ct 
des pays marecageux,' Paris, 1789. 


inquiries made iu tlic malavidus regions of the Sologne by 
Lafont (p. q) and others, tliat the volume of these gases in 
the air of marshes ranges from little to nothing, and that 
owing to their diffusibility, they can act only in a very 
diluted state. Lastly, the prevalence of malarial fever is by 
no means proved in the neighbourhood of the localities 
where the aforesaid gaseous combinations are mostly 
detected, as in the vicinity of certain manufactories, sxilphur 
mines, and the like. There remains only the conjecture 
that the malarial poison is represented by hitherto undis- 
covered gases or mixtures of gases, capable of producing their 
specific effect in the highest possible state of attenuation, an 
assumption for which there is at present no actual foundation. 
The zymotic theory is based upon the doctrine of ferment- 
action. It coincides, therefore, in parts with the parasitic 
theory ; but, in contrast to the latter, it leaves the question 
open, whether it is the excitants of decomposition as such, or 
whether it is the formed products of decomposition or the 
already defunct fermentative producers, that act as poisons, 
producing the special pathogenetic effect upon the organism. 
Of all the theories that have hitherto become current as to 
the nature of the malarial poison, that which asserts the 
parasitic character of the disease meets with most approval at 
present, inasmuch as it is supported by other analogous facts 
in the etiology of disease, and has at least this preference 
that it satisfactorily explains the peculiarities in the occur- 
rence and course of malarial fever as an endemic and as an 

Mitchell' was the first to approach in a scientific spirit the question 
of the parasitic nature of the infective diseases, and particularly of 
malarial fever. Soon after the appearance of his work, Barnes- also 
declared that inquiries into the malarial fever in Fort Scott, Kansas, 
gave much probability to the assumption of the parasitic nature of the 
malarial poison ; and to the same effect was the opinion of Gigot from 
his obsei'vations made in the department of the Indre. Lemairc^ exa- 
mined with the microscope the mist that rose and condensed over the 
marshes of the Sologne, and satisfied himself that it contained abundant 

' ' On the Cryptogamons Origin of Malarions and Epidemic Fevers,' Pbilad., 
^ 'U. S. Army Reports,' 1859, p. 163. 
^ ' Compt. rend, de I'Acad.,' 1864, i, p. 426, ii, p. 317. 


lower organisms whicli grew out of the cells and spores contained in 
the moisture, and seemed to be related to the malaria there prevalent. 
Then came the statement of Massy, that at a time when severe malarial 
fever was prevalent in Ceylon, he had found a (microscopic) fungus 
which floated in enormous masses in the air, was precipitated every- 
where, was even found in the urine and sputa of the sick, and represented, 
as he believed, the true malarial poison. In like manner Baxa and 
Wiener thought that they were justified in assuming that, among the 
lower organisms met with in the marshes of Pola, one in particular, 
having the form of a simple cell, was the malarial fungus. Holden ex- 
plained the above-mentioned outbreak of malarial fever on l)oard a ship 
of war (p, 285) as follows : — The algae belonging to the family of Thallo- 
phytes, which he had found in the infected store rooms, were harmless 
in themselves, but they had taken on poisonoi^s properties from combining 
with the sulphiu-etted hydrogen set free under the circumstances named, 
and had so produced the disease. Just about the time of Holden's an- 
nouncement, there appeared the well-known paper of Salisbury, adduc- 
ing evidence that in the soil of malarious foci on the banks of the Ohio 
and Mississippi, there grew a species of alga (Palmella) whose spores 
were carried into the atmosphere by the ascending current of air ; they 
thus came within reach of the respiratory and digestive organs of the 
individual, and he thought to prove by an experiment, which we shall 
mention afterwards, that they were the malarial poison. The announce- 
ment of Salisbury excited general attention, and if the conclusions 
which he drew from his studies did not escape some well-founded objec- 
tions, they were at the same time abundantly confirmed. Thus Van 
den Corput' stated that, when he was a student, he had been several 
times ill with malarial fever while growing algoB and other marsh 
plants in his bedroom ; and Hannon^ declared that he had observed 
the same thing himself in 1S43 at a time when he was engaged in the 
study of the fresh-water alga). Shortly after, Balestra published the 
result of his inquiries into the algaj present in the Pontine Marshes ; he 
showed that, besides numerous low organisms in the water, there was 
one species of alga that grew with -enormous rapidity when it was ex- 
posed to air and light, and whose spores could be detected in the atmo- 
sphere over the Pontine Marshes, as well as over the Roman Campagna. 
He took the fever himself twice after .drawing deep breaths over a 
vessel containing marsh water so infected ; and he satisfied himself also 
that, on the addition of sulphate of soda, arsenious acid, or sulphate 
of quinine, not only did the reproduction of these algse cease, but they 
and their spores underwent a change in their structure ; and this led 
him to think that there need be no hesitation in designating these 
microphytes or their spores as a true cause, and perhaps the only cause, 
of malarial fever. Selmi^ came to almost the same conclusion in his 
investigation of the mist overhanging the marshes of Mantua. In a 

- ' Journ. de med. de Bruxel.,' 1866, Marcli, p. 3.^0. ' lb., May, p. 497. 

^ ' II miasma palustre,' Padova, 1871. (Also given in abstract in ' II Morgagni,' 
1873, P- 437-) 



case of malarial fever observed by Sclmrtz' at Zwickau, wliere the dis- 
ease is extremely rai'O, the question was to account for the illness of a 
person who cultivated Oscillaria in his bedroom in the course of his 
botanical studies; the Palmella, as Schurtz conjectures, may have some 
genetic relations to the Oscillaria. The observations of Salisbury 
were further confirmed by Bartlett,- who found the microphytes described 
by the former in enormous diffusion in the malarious localities on the 
Mississippi near Keokuk, where the disease was universal : " The course 
of this disease," said Bartlett, " seemed pari jjossit with that of the 
plant." Magnin, who has investigated this question in the marshes of 
the Dombes, is also of opinion that the cause of the disease is to be 
referred to a microphyte, one of the species of Oscillaria ; while Lanzi,^ 
basing on his observations made in the Roman Campagnaand the Pontine 
Marshes, throws out the conjecture that the formation of the malarial 
poison is a matter of peculiar degeneration of the cells of algae, which 
become filled with black granules, identical perhaj)s with the sphaero- 
bacteriumof Cohn or the bacteridium brunneum (Schroter), and consti- 
tuting the true infecting matter. Klebs and Tommasi-Crudeli believe 
that the question of the production of malarial diseases, by the taking 
up of low vegetable organisms, has been finally settled by their experi- 
ments in the Roman Campagna and in the Pontine Marshes. Both in 
the soil and in the air of these malarious localities, they found a kind 
of bacillus in the form of rods and elongated oval moving spores, which, 
when isolated and cultivated, produced the most marked malarial sick- 
ness in the animals which received them. The fevers vaiied from the 
mildest to the most intense or so-called pernicious kind, fatal in twenty- 
foiu' hoxirs ; the firm swelling of the spleen and the melanaemia which 
were observed at the same time, afforded further evidence of the identity 
of these artificially produced fevers with the malarial sickness occurring 
in man. The absence of this bacillus malaria) from the stagnant water 
of those pai'ts, although it was unusually rich in other lower organisms, 
was also accounted for by the experiments ; large quantities of water 
either prevented the development of this malarial poison altogether, or 
rendered the existing germs of the disease powerless. In the body of 
the infected animal the bacillus was most abundantly developed in the 
spleen and the marrow of the bones, where in some cases there were 
long homogeneous threads from 0*06 to O'OS mm. in length and 6 
micro-millimeti-es in thickness. Marchiafava has found the same 
bacillus malaria; in the bodies of several persons who died in Rome 
of pernicious malarial fever, and Griffini has confirmed the occurrence 
of them in the Lombard rice-fields. 

It need hardly be said that, with all these observations, 
the question of parasitic malaria is not yet absolutely 
solved j gross errors underlie some of the observations, 

' Arcbiv dcr Ilcilkinidc, 1868, p. 69. 

' Brit. Med. Journ.,' 1873, .Ian., p. 5.^. 

2 Med. Times and Gaz.,' 1876, Dec. 2, p. 625. 


particularly those of Salisbury^ as Wood/ llarkness/ and 
Weir^ have shown. It must rest with the future to decide 
upon the value of this theory. 

A peculiar theory of malaria, assigning to it a telluric 
origin, has lately been set up by Colin. In his view, it is 
essentially an affair of a power issuing from the soil, a 
"puissance vegetative du sol," which becomes a cause of 
disease when the power is not exhausted by cultivated plants. 
" So far," he says,'* " from having to search in the vegeta- 
tion of the marsh for the cause of the fever, I believe that 
it is rather in the inverse condition, in the absence of this 
vegetation, that one is likely to find it. In my view, indeed, 
the fever is caused most of all by the vegetative power of 
the soil whenever that power is not called into action, when 
it is not exhausted by plants sufficiently abundant to use it 
up," and in this sense he designates the disease as an 
" intoxication tellurique." 

Finally, there have not been wanting attempts to refer the 
origin of the disease to the toxic excretions of living organisms, 
lilant or animal, instead of to the products of decomposition 
of organic matters or to parasitic bodies. Boudin^ has con- 
jectured that the ethereal oil excreted by certain plants, 
especially AnthoxantJium odoratum, Chara vulgaris, some 
rhizophora3, and others, represents the malarial poison ; and 
this view appears, from the statement of Yaughan,^ to have 
been lately received with favour in the Academy of Medicine 
of Cincinnati. Bouchardat^ has set out with, a similar idea, 
only that he substitutes the animal kingdom ; he believes 
that the malarial poison is an excreted product of certain 
infusoria vegetating in marshes or in a damp soil. " This 
is a hypothesis," he adds, "' which gives the best account of 
the facts obseiwed ; to speak of this substance as allied to 
the poisons introduced by animals {les venins) is only to 
assign to the facts their most legitimate interpretation." The 
innocuousness of certain marshes is explained by Bouchardat 

1 ' Aruer. Journ. of Med. Sc.,' 1868, Oct., p. ^z^. 

- ' Boston Med. and Surg. Journ.,' 1869, Jan., n.s., ii, p. 369. 

■'* lb., 1870, Dec., n.s., vi, p. 390. "• ' Traite,' p. 14. 

* 'Traite des ficvres intermittentes,' Pai-is, 1841. 

^ 'Philadel. Med. and Surg. Reporter,' 1871, Dec, p. S51. 

^ ' Annuaire de therapeutique,' 1866, p, 399, 


in this wiso : either that they do not contain those " infusoires 
toxifcres " at all^ or that certain vegetable matters occur in 
them coincidentally, which nullify the poisonous effects of the 

However far wo may still be in science from getting a 
definite answer to the question of the nature of the malarial 
poison, and on however inadequate grounds all the numerous 
attempts designed to explain it may appear to rest, there is 
one idea running, like a red thread, through all those hypo- 
theses, which seems to me to bo of fundamental importance 
for the final solution of the problem. Whether we regard 
the malarious substance as a product of the decomposition 
of organic matters, or as jiarasites, or as an animal or vege- 
table poison, or in what way soever, we shall always ascribe 
specijic properties to it, and always come therefore in the 
end to some specific source whence it lias arisen. We are 
therefore driven to the supposition that the morbid poison 
develops only from, or within, certain organic matters (animal 
or vegetable) ; and so the inquiry directs itself in the first 
instance to the study of the lower fauna and flora both of 
the localities were malarial fevers are endemic, and also of 
those which are exempt from the disease, with a view to 
ascertaining, from a comparison of the results so obtained, 
first of all what animal or vegetable forms the production of 
malaria appears to be associated with. It is not the amount 
of vegetation (Avhich has hitherto so fixed the attention of 
inquirers) as the specificity of it, which ought, in my opinion,, 
to come mostly into consideration ; it is this specificity that 
appears adapted likewise to explain the prevalence of the 
disease in some very barren regions, as well as its absence 
from other tracts of country Avith a luxuriant vegetation ;. 
and, finally, to explain the fluctuations in the amount of 
sickness, the appearance of it as an endemic when agriculture 
is neglected, and the disappearance of it when the cultivation 
of the soil has been changed or reduced to greater regularity,. 
Along with the knowledge of such living species, we ought 
to aim at a deeper insight into the pathogenetic influence of 
the soil itself, inasmuch as both its physical and geological 
peculiarities may determine the character of the fauna and 
flora supported by it. 


§ 78. One Malarial Poison or Several ? 

■So long as wo remain ignorant of the nature of tlie 
malarial poison, wo shall bo working merely on a basis of 
probabilities in attempting to answer the question whether 
there are various morbid 'poisons underlying the various forms 
of malarial disease, or whether there is only one malarial 
poison, whose kind of effect is various according to the quan- 
tity in which it acts, and according to the predisposition of 
the individual affected by it. From the standpoint of criti- 
cism, I must decide in favour of the second notion ; because 
experience shows that the disease, both in the individual and 
in the epidemic, exhibits transitions from one form to the 
other, that the intensity of the disease at one and the same 
place depends upon vicissitudes of external conditions, espe- 
cially heat and moisture, and that the form of sickness stands 
in a definite relation to the power of resistance in the 
organism that has been invaded by the morbific cause. 
These are the considerations that justify us in bringing 
together all the forms of disease hero spoken of into the 
single category of ^'malarial disease." 

§ 79. Alleged Diffusion by the Wind — Absence op Con- 
tagious Power. 

There can be no doubt that the malaria generated in the 
soil may exert its influence at a distance from its centre of 
origin, and that this diffusion of the morbid poison is effected 
by the wind. Lancisi was the first to throw out the idea that 
the wind may be regarded as a carrier of the malarial poison ;^ 
and even if the assumption on which he built his opinion was 
an erroneous one," there have been since then very many and 

- Laucisi, as is well known, believed that the endemic malaria of the Iloman 
Campagna owed its origin to the emanations of the Pontine Marshes finding free 
access to the Campagna in consequence of the cutting down of the sacred groves 
•during the pontificate of Gregory XIII. He had forgotten, however, that 
between those marshes and the Campagna there are the Alban Hills, which 
•would afford a much more certain protection than the woods, supposing always 


unambiguous observations to prove that tlie apppearaucc and 
prevalence of tlio disease is often subject to the influence of 
winds blowing over niarslics and otlier sources of malaria, 
and carrying tlie poison to places otherwise exempt from 
the disease ; it is also proved that ascending currents of air 
may carry it to certain altitudes, while, on the other hand, 
barriers of various kinds, such as hills and elevations of the 
ground, belts of trees, walls, and the like, lying in the track 
of the winds charged with malaria, may afford a protection 
from the poison to the localities situated behind them. 

Facts of tliis class are reported from almost all malarious regions. 
Thus Le Gendre (p. 26) obsei-ves that the hill country in Medoc is 
visited Ijy malarial fever only when it is exposed to the winds passing 
over the adjoining marshy plain, but never when the opposite wind is 
blowing ; and similar observations are published by Cornay for Roche- 
fort and by Croigneau for E-ochelle. Mondineau states (p. 15) : "It is 
quite certain that in the districts of the Canton of Houeilles, intei- 
mittent fevers have become much more rare, and everywhere less severe 
since the immense forests of shore pines have grown up to form a 
natural barrier to the propagation of the miasm." Jilek (p. 59) shows 
that, in Pola, those parts of the town suffer chiefly from malaria which 
are most exposed to the winds blowing from the neighbouring marshes. 
Moore points out (p. 289) that the island-like plain of Cutch, situated 
close to the salt-marshes of Rann, must needs be infested by the 
severest malarial fevers were it not that for ten months of the year the 
■wind blows from the island to the marshes. Wilcocks found, in the 
severe epidemic of malarial fever that prevailed in Philadelphia in 1846, 
that the streets and rows of houses in the quarter of the town most 
affected, were nearly always those exposed to the wind from the south. 
Coons gives the following interesting case from the epidemic of 1826 in 
Alabama : Near Moulton, and half a mile from a lake, there is a large 
farm whose inhabitants enjoyed excellent health up to 1826; in the 
summer of that year, a dense wood which separated the farm from the 
lake was cixt down, so that the j)lantation was exposed to the winds 
blowing over the marshy lake, and a year after, so intense an epidemic 
of malarial disease broke out that only three or four out of the 150 
persons on the plantation escaped the sickness. Obseiwations to the 
same effect are given by Wooten for Lowndesborough :^ here, also, it 
Avas an affair of a plantation separated by a thick belt of wood from the 
swampy shores of a creek a quarter of a mile away; the wood was cut 
down in the winter of 1842-3, and in the following summer the negro 
hands on the plantation, who had hitherto escaped the malarial sick- 
that the exhalations from the mar.slies can in fact make themselves felt at so 
great a distance. 

J Lewis, 'Med. Hist, of Alabama,' ]). 17. 


ness, suflfered so much fi-om it, that the proprietor was obliged to 
quarter them on the other side of the river, which was still sheltered by 
a wood; whereupon the sickness abated and the former state of health 
was restored. Jackson (III, p. 6i) publishes the following observation 
made by him in 1778 in Jamaica: near King's Bridge, some two 
hundred paces from a swamp, a camp was pitched on a dry and tole- 
rably elevated piece of ground which was exposed to the winds blowing 
across the swamp ; it was especially the more elevated part on the right 
that was struck by the wind, and malarial fever very soon broke out 
there, while the lower part on the left remained almost exempt from it. 
The soldiers whose tents were pitched on a height in front of the camp 
suffered most, being most exposed to the effects of the wind, and none 
of them escaped the epidemic. 

It would bo hardly possible to find a numerical expression 
for the distance to which malaria may be carried by the 
wind ; it is most probable that it is limited to a very small 
range relatively. At least all the most reliable observations 
made on land bear this out_, while experiences as to the 
diffusion of the disease from the shore to vessels anchored in 
the immediate neighbourhood is still more conclusive. All 
those experiences go to show that the crows of ships lying so 
close to the shore or the coast as to be necessarily affected 
by the land wind, are almost always exempted from the 
disease so long as they do not set foot on tho infected shore ; 
and this applies even to the most intense malarious spots. 

Lind long ago remarked : " Noxii vapores, qui paludibus 
emanent, hand longe patent ; nam persaspe naves a littore 
haud multum remotas a labo prorsus immunes vidimus. ^^ 
The fact has been subsequently confirmed by Badenoch and 
Allan for the Comoro Islands and the coast of Madagascar, 
and by Hitchie and Griffon for the Congo Coast, to this 
extent at least that only the very closest proximity to the 
shore has any influence on the crew, and then only in a very 
limited degree. '^ When the ships watered at Rock Fort," 
says Blane,^ "they found that if they anchored close to the 
shore, so as to smell the land air, the health of the men was 
affected ; but upon removing two cables' length, no incon- 
venience was perceived." Rattray makes the same remark 
for ships lying in the harbour of Hong Kong : " While the 
fever . , . . was fatally prevalent on shore, the ships 

^ 'Observations on the Diseases incident to Seamen/ Lond., 1799, p. 221. 


in harbour, even when lying at very short distances from the 
shore, ai-e usually or often exempt from its ravages.^' 

Least of all is one justified in attributing to a diffusion of 
malaria by atmospheric currents, the great malarial epidemics 
and pandemics, whose oi'igin for the present admits of no 
adequate explanation founded on facts ; in not a single case 
has the disease on a large scale been shown by observations 
to have spread according to the direction of the wind. In 
like manner, all those observations which have been adduced 
to prove the diffusion of malaria by means of drinking-water, 
do not, in my view, bear the construction that tlio ^vriters 
put upon them. 

Question of drinhing loater. — Thus Jussieu,' in liis account of the 
epidemic of malarial fever in Paris in 1731, makes out tlie cause to have 
been the use of Seine water contaminated by i-otting water-plants and 
confei'va). Mejnne (p. 364) communicates some observations from 
Belgium on an outbreak of malarial fever in consequence of partaking 
of marsh water. Similar statements are made by Perier (p. 10) for 
Algiers, and by Lord (p. 461) for the delta of the Indus, where the 
natives are so convinced of the infective properties of well water that 
they say no stranger can drink it for two weeks together without taking 
malarial fever, and the author adds that he has had occasion to assure 
himself of this fact during a halt of the English troops for only a few days 
in Bahawal Khan. Reumert" narrates in his account of the medical 
topography of Fridericia, that there occurred in 1855, in a quarter of 
the town much affected by malarial fever, a sei-ies of cases limited 
to such persons as had taken their drinking water from a particiilar 
spring. Parkes^ mentions that he visited the marshy plain of Troy 
during the Crimean War, and there discovered that those of the inhabit- 
ants who drink marsh water suffer from malarial fever all the year, 
while others who use pure spring water suffer only in summer and 
autumn. Boudin- gives the following : On board a French ship of war 
bound from Bona (Algiers) to Marseilles, a malignant epidemic of 
malarial fever broke out at sea, thirteen men dying out of a crew of 229, 
while ninety-eight were more or less severely ill, and had to be sent 
into hospital at Marseilles ; it came out, on inquiry, that the vessel had 
shipped at Bona several casks of marshy water, which had given occa- 
sion' to lively dissatisfaction among the crew on account of its disagree- 
able smell and taste, and that not a single case of sickness had occurred 
among those of the crew who had drunk pure water. 

1 Mem. de I'Acad. des So. Ann.,' 17.^3, p. 351. 
" ' Dansko Sundhctscoll. AarsbiTotiiing for 18/55,' P- 67. 
^ 'Manual of Tractical Hygiene,' London, i860, p. 71. 
^ ' Geogr. ct statist, mod.,' Taris, 1857, i, p. 142. 


To all these statements, and many more like tliem, there 
is, in my opinion, no definite value to be attached for 
answering- tlio question at issue ; and that is also the 
opinion which Colin has expressed in the most decided way 
on the strength of his experiences in Algiers and at Rome. 
Much of this so-called experience rests plainly upon mis- 
takes, or at least on erroneous suppositions ; in every case, 
it is a question of individuals sickening who had been other- 
wise exposed to malarious influences ; and even if one were to 
admit that the partaking of putrid or marshy water may 
have an influence on the production of malaria, the question 
is not one of specific cause, but of such an injurious influence 
as would increase the predisposition of the individual to 
malarial sickness, or to the occurrence of relapses, by 
lowering his power of resistance. 

The notion that a contagium develops in the course of the 
-malarial process, or, in other words, that the morbid poison 
reproduces itself Avitliin the body of the malarial patient, gets 
■eliminated therefrom, and conveyed to other individuals, 
whereby it brings about the diffusion of the disease — this 
notion must be dismissed in the most decided way, according 
to the opinion of all observers and the experiences of all the 
great epidemics.^ But it is otherwise with the question 
whether there is any conveyance of the malarial poison, 
engendered in or upon the soil, by means of the soil itself, 
or of other objects to which this poison may cling. It is 
somewhat remarkable that no attention has been given to 
that particular statements of Salisbury's on the parasitic 
character of the malarial poison, which, in my opinion, 
appears to be the most important of them all, assuming 
always the trustworthiness of the facts. I refer to the 
observations which seem to furnish proof that the malarial 
poison may he conveyed from place to place. In order to 
prove the fever-producing property of the palmella, he 
devised the following experiment : 

He filled several boxes witli earth taken ft-om an extremely malarious 
soil and abundantly penetrated and covered witli alga3 ; be then took 

' The observations adduced by Thomas (' Archiv der Heilkd.,' 1866, p. 307), 
to prove the contagiousness of malarial fevers (probable conveyance of the disease 
from infants to nurses and vice versa) cannot well be regarded as convincing. 


tbem to a house about 300' above tlie level of the river, in a perfectly 
dry situation, distant some five miles from the nearest malarious 
locality, and where there had never been a case of malarial fever. They 
were placed on the window-sill of a room on the second floor, used as a 
bedroom by two young men, and care was taken that the "window 
should not be closed during the night. On the sixth day after the 
boxes were deposited, both the inmates of this room complained of being 
xmwell; on the twelfth day, one of them had the first decided attack of 
ague, and the other on the fourteenth day; the fever took a tertian 
type, and soon disappeared under the use of quinine; all the while four 
members of the family who slept in the lower rooms of the house 
escaped the disease. A second experiment resulted the same way ; it 
took place at a building adjoining the house already mentioned, in a 
room occupied by a man and two boys ; on the tenth day one of the 
boys took intermittent fever, and the other boy on the thirteenth day, 
but the man continued well. 

It must remain an open question wlietlier palmclla spores 
contained in these boxes and conveyed by tlic currents of air 
into tbe room, gave occasion to tlie sickness; at all events 
the assumption appears well founded that something was 
brought into the rooms in the boxes containing the earth, 
which had a morbific eifect. In that sense also we may 
perhaps interpret an observation lately recorded by Sawyer.^ 

The aixthor, who resides in a malai-ious part of Illinois, visited a friend 
at Milton, Mass., and fell ill there of intermittent fever. The lady of 
the house, who Interested herself greatly on the patient's account, and 
who had never seen a case of ague before, had a slight aguish attack of 
fever and chill on the fifth day, with gastric disturbance ; but she set 
aside the idea that she could possibly be ill of ague, as the disease was 
quite unknown in Milton, or occiirred only now and then in imported 
cases. However, she had a more severe attack the day after, and on 
the ninth day the first pronounced paroxysm of ague occurred, and, 
with that, aU doubt as to the nature of the disease vanished. 

The possibility of the patient having brought the malarial 
poison with him from home in his clothes or other effects, 
and so given rise to the lady's illness, cannot on the face of 
it be contested ; and thus the question arises whether the 
malarial poison is not transportable, and whether we may not 
perhaps interpret the development of malarial epidemics in 
places otherwise exempt from the disease, as well as the 
formq,tion of new endemic foci, in the sense that the morbid 
poison, somehow conveyed, has landed on a soil that renders 
1 ' Uoston Med. and Surg. Jouru.,' 1867, Dec, p. 538. 


its reproduction possible, cither for a time or permauontly. 
We may fiud a corroboratiou of tliis in the outbreak and 
spread of the disease in Sweden (Bergman), Finhmd (Hjelt), 
and other countries; and it may be that, from this point of 
view, Lacaze is right when he says of the malarial epidemic 
that broke out in Reunion in 18C8 : " The fever had existed 
barely three years in Mauritius, when the first cases were 
observed in Reunion. There is a probability, amounting 
almost to a certainty, that an importation had taken place 
thither from the Mauritius." 

The last question belonging to the history of the malarial 
diseases relates to the alleged antagonism in space or area 
between those diseases on the one hand, and typhoid fever 
and consumption on the other. This question will be duly 
noticed in the accounts of the latter diseases. 


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§ 80. Peculiar Geographical Distribution. Chronology of 


Measured by tlio range of its distribution over the earth's 
surface, yellow fever takes one of the lowest places among 
acute infective diseases. If we disregard its isolated appear- 
ances at several points on the western shores of Europe, and 
its quite recent establishment as a prevalent form of sickness 
on the Atlantic and Pacific coasts of South America, there 
remain only two among the greater regions of the globe to 
form the seat of yellow fever : on the one hand, the shores 
of the Gulf of Mexico, including the West Indies, and part 
of the Atlantic coast of the United States, and, on the other 
hand, a part of the West Coast of Africa. 

The earliest history of yellow fever in the former of 
these two regions is enveloped in an obscurity which wo 
cannot now enlighten. In particular, there is no way of 
getting an answer to tho question whether the disease was 
prevalent there, and, if so, to what extent, before the 
arrival of European colonists ; or to the question, when 
and under Avhat circumstances it first appeared among 
the new comers. It is not only the defectiveness of 
the records from these earliest times of our intercouse with 
the Western Hemisphere, that renders all historical research 
on the subject illusory ; a still more serious impediment, and 
one that has continued in force down to the most recent 
times, is the frequent confounding of yellow fever with 
bilious remittent malarial fevers, especially with febris 
remittens hgemorrhagica. All the observations dating from 


the sixteentli century, by Herrera/ Dutertre/ Rocliefort/ 
and others, on the destructive pestilences which had raged 
anion Of the natives of the West Indies before the arrival of 
Europeans, as well as the accounts of Ilerrera,* Oviedo,^ 
Lopez de Gomara,*" and others, as to the disastrous sickness 
among the first settlers in Domingo in 1494 and 1504, in 
Porto Rico in 1508 and 15 13, and on the Gulf of Daricn in 
1509 and 1 5 14, afford scarcely any safe indication of the 
nature of the disease, for the reason that they are derived 
from non-medical observers ; while it is at the same time 
certain that the Europeans (Spaniards, Fi^enchmen, and 
Englishmen) suffered, soon after settling in North and South 
America, from the severest forms of malarial fever, to such 
an extent that numerous settlements were depopulated in a 
few years, and whole armies perished. Still less credence 
is due to the opinion adopted by Webster ^ that the severe 
pestilences mentioned by Hutchinson*^ and Gookin^as having 
occurred during the sixteenth century among the natives on 
the East Coast of North America, are to bo taken as yellow 
fever ; for it is expressly stated that they prevailed in the 
winter time, during severe cold, exclusively in the wigwams 
of the Indians, the European settlers escaping them. Neither 
is there any reason for identifying with yellow fever the 
Mexican pestilence mentioned by Humboldt^^ nnder the 
colloquial name of '^ Matlazahuatl j" for that also was pre- 
valent, in the epidemics that are known (1545, 1576, 1736- 
37, 1761-62), almost exclusively among the natives of the 
country, and it affected only the interior and the table-laud 
of Mexico, sparing the coast regions. 

The first reliable accounts of yellow fever date from the 
middle of the seventeenth century ; they tell of the importa- 

' ' Historia general de los Echos de los CastcUauos in las Islas y Terra firina 
del Marc Oceano,' Madrid, 1601. 

"^ ' Hist, gonei'. des Antilles Fran^.,' Paris, 1667. 

^ 'Hist, naturelle et morale dcs lies Antilles,' Lyons, 1667, ii, p. 475. 

■* L. c, l)k. i, cliap. 10, 12; bk. x, cliap. 14. 

^ 'La Historia general des las Indias,' Madrid, 1547, bk. ii, chap. 13. 

^ ' La Historia des las Indias,' Medina, 1553, bk. i, chap. 2. 

7 ' History,' i, p. 176. 

^ ' History of Massachusetts,' i, p. 34. 

5 ' Historical Collections,' p. 8. 

10 ' Essai politique sur le Eoyaume de la Nouvelle Espagne,' i, p. 352. 



tion of the disease from place to place, and from island to 
island ; and they advert to the circumstance that it was 
especially the now arrivals that were visited by the sickness 
most, and that not only the settlors but also the crews of 
merchant sliips and ships of war at anchor in the ports of 
the West Indies were menaced to a great extent by the 
disease. In the following pages I have represented in 
tabular form the epidemic history of yellow fever in the 
above-named regions (American), as far as it has become 
known to us ; and for the better surveying of it, I have 
arranged the epidemics in two tables, the one gi\nng the 
general chronology, and the other the localities (with dates) 
in the order of their latitude. 

I. Chronological .survey of the epidemics of yelloiv fever, in 
the West Indies, North America, Central America, and 
the Mexican Gulf Coast of South America. 

1635 Guadeloupe: Dutertre i, 81. 
1640 Guadeloupe: id. 99. 

1647 Barbadoes : Li^on (History o£ Barbadoes, Lond., 1657) p. 36. 

1648 Guadeloupe: Dutei-tre i, 423. — St. Kitts : id., ib.' 

1652 St. Kitts : Maurile de St. Michael (Voyage des lies en 
Amerique, 1652) p. 45. 

1655 Jamaica: Moseley, 422. 

1656 Domingo : id., ib., and Moveau (I), 60. 
1665 Sta. Lucia: Dutertre iii, 86, 244. 

1671 Jamaica: Trapbam (State of Health of Jamaica in 1679, 

Lend.), p. 81. 
1688 Mai'tinique: Labat (Nouv. Yoyage aux lies dc I'Amerique, 

Paris, 1722) i, 72, 
1690 Barbadoes: Hughes (Natural Histoiy of Barbadoes, Lond., 

1750) p. 37. — Domingo: Moseley, Moreau, 11. cc. — Santa 

Cruz : Moreau, 1. c. 

1693 Martinique: Labat. — Caracas: Humboldt (Voyage) ii, 400. 

— Boston: Webster i, 207; La Roche (II) i, 48.- — Phila- 
delphia : La Roche (II) i, 49. — Charleston : id., ib. 

1 694 Barbadoes : Ligon. 

1 696 Domingo, Martinique, and other West Indian^Islands ; Moreau 
(I), p. 53. — Venezuela. 

' See also Webster (in the 'New York Mod. Kepos.,' vii, p. 322), wlio 
supplies information about the epidemic from the manuscript records of the 
historian Hubbard. 

' It is questionable whetbcr this account relates really to Boston, or not more 
probably to a more southern port, New York or Newport. 







1 706 
1721 — 24 










1 741 







The West Indies over a wide extent : Bally {1), p. 36. — Vera 

Cruz (first epidemic): Heinemann (II). — Bermuda: 

Barrow, p. 290. — Philadelphia : Webster i, 21 1 ; La Roche 

(II) i, 50. — Charleston: Webster i, 212; Ramsay (I), 

p. 96. 
New York (August — Sept.): Webster i, 217; Bard. — Bay 

of Biloxi (first French colony on the Gulf Coast) : Drake 

ii, 215 ; Lewis (II). 
Guadeloupe, Martiniqiie : Labat. — Charleston : Hewatt 

(Account of the Rise and Progress of the Colonies of S. 

Carolina, &c., Lond., 1779) i, 142. 
Domingo, Martinique : Labat, FeuiUe (Joum. d'observ. dans 

la Nouvelle Espagne, &c., Paris, 1725), p. 186, — Mobile : 

Lewis (II). 
Martinique : FeuiUe, p. 187. 

Barbadoes : Chisholm ii, 177 ; Brown (II), p. 12. 
Bai'badoes : Warren (I), Toune. 
Yera Cruz ; Clavigero (Hist, de la Mexique) i, 117. 
Porto Bello : Ulloa (Voyage histor., Paris, 1752), p. 84. 
Charleston (in Summer) : Hewatt, p. 317. 
Antigua : Bally (I) p. 40. — Porto Bello : Ulloa. 
Domingo (on board the fleet arrived from Porto Bello) : 

Bancroft (I), p. 336. 
Charleston (May — Oct.) : Ramsay (I), p. 36 and (II), Moultrie. 
Barbadoes : Warren (I), p. 4. 
Domingo : Desportes i, pp. 40, 66, 74, 86. 
Norfolk (Va.) : Mitchell (I). 

Charleston (August and fol.): Ramsay (I), p. 36. 
Cartagena, Porto Bello, Panama, Vera Cruz : De Gastelbondo 

(Tratado del Mcthodo curativo .... de la Enfermedad del 

Vomito negro, &c., Cartagena, 1753). 

DomSSo] (June— Dec.) : Desportes i, 97, 1 10, 114. 

Jamaica (in the English fleet on its arrival from Cartagena) : 

Hume (I), p. 230, Williams (I), p. 11. 
Norfolk (Va.): Mitchell (I).— Philadelphia (July and fol.), 

Currie (I), p. 211. 
Domingo (Summer and Autumn): Desportes i, pp. 129, 133, 

136, 138, 166. 
New York (July — Oct.): Webster i, p. 238. — Newhaven : 

Munson, in 'Additional Facts,' &c., j). 54. 
New York : Webster i, 239, 341. — Charleston (June — Sept.): 

Ramsay (I), p. 39, Monltrie, p. 165. 
Philadelphia (June — Oct.): Currie (I), p. 212, Pemberton in 

'Additional Facts,' &c., p. 6; Chew, ib., p. 11, Bond, 

Charleston (August — Oct.) : Moultrie, p. 171 ; Lining, p. 419. 
Martinique : Bally (I), p. 49. 
Curacao (April) : Winds in Lind, p. no. 
Antigua (Autumn) : McKittrick, p. 107. 
Antigua: Lind, p. 185. 
Surinam (first epidemic) : Fermin. — Curasao (in autumn) : 

Rouppe, p. 303. 
Havana: Moreau (I), p. 73, Webster i, 251. — Philadelphia 

(August— Nov.) : Redman in 'Additional Facts,' &c., p. 19 ; 

Willing, ibid., p. 9, Rush (I), p. 15. 




J765 — 66 

T770 — 72 
1779 — 80 

1781 — 82 







Cayenne: Bajon ii, 46 ; Campct, p. 73. 

Mobile: Romans (' Hist, of Florida,' Pbilad., 1776), p. 13; 
Drake ii, 216. — Pcnsacohi: Liud, p. 37, Romans. 

Antifjua: Lind, p. 213. 

Sta. Lncia : Leblond, p. 1 54. 

Grenada: Leblond, pp. 166-7. 

Martinique: Moroau (I), p. 82, after Rocliambeau. 

Bermuda : Barrow, Smart. 

Jamaica, St. Lucia: Bally (I), p. 56.— Havana: Caillot. 

Havana, St. Domingo : Bertlie, p. 1 64, after Fr. Balmis. 

Baltimore : Webster i, 274. 

Cayenne : Leblond, p. 209. — New Orleans (fii-st epidemic) : 
Drake ii, 201. — New York : Addoms, Carey, p. 85. 

Charleston (August — Sej)t.) : Ramsay (II), Harris (III). 

Cai-acas (October) : Rush (I), p. 390. — Porto Bello : Moreau 
(I), p. 156. — Demerara, Trinidad : Chisholm ii, 201,228. 
— Tobago (July) : Ibid., p. 212. — Grenada (March — Sept.) : 
Ibid., i, 96 ; Stewart, Smith (II). — St. Vincent (April) : 
Chisholm ii, 144. — Barbadoes (May): Ibid., p. iSo; Romay, 
168. — Martinique (October): Chisholm ii, 112. — Domi- 
nica (June — Oct.): Ibid., ii, 254; Clark (I). — Antigua, 
St. Kitts (June) : Chisholm ii, 281, 291. — Santa Cruz 
(August — Oct.) : Ibid., 342. — St. Thomas (November) : 
Ibid., 320. — San Domingo : Moreau (I), 73. — Jamaica 
(June and fol.) : Lempriere ii, 22, Rule. — Surinam : 
Stille. — Philadeli)hia (August — Dec.) : Rush (I), Curly, 
Currie (II, III), 'Facts and Observations,' Deveze (II), 
Pascalis (I), La Roche (II) i, 64. 

Demerara: Chisholm ii, 201. — Vera Cruz ■ — Grenada 
(February) : Chisholm i, 136 ; Stewart. — Dominica (July — 
Dec): Clark (I), 5. — Martinique (March): Pym, p. n; 
Gilpin (I). St. Thomas, Santa Cruz : Chisholm ii, 320, 342. — 
Havana (June — August.) : Romay, Holliday. — Jamaica 
(June — August.) : Lempriere ii, 52. — Charleston (July — 
Nov.) : Ramsay (I), 36, Johnson (I).— Baltimore: Valentin 
(II), 71 ; Drysdale. — Philadelphia (August : Rush (II). — 
New York : Rush (II), 218. — New Haven (June— Nov.) : 
Monson, "Webster i, 302 ; ii, 340. 

Demerara: Eymann. — Grenada: Chisholm i, 13S; ii, 231; 
Stewart. — St. Vincent, St. Thomas : Chisholm ii, 154, 320. 
— Martinique (January) : Gillespie (I) 11. — Guadeloupe: 
Bishopp in Pym 118. — Domingo : Moreau (I) 74. — Jamaica 
(June — August) : Walker, Lempriere ii, 22, 55, Todd. — 
Norfolk (August — Oct.): Valentin (I), 85; Taylor, Ramsay 
(III). — New York (July) : Smith (VI), Seaman (I). Bayley 
(I), Hosack (I). — New London (August to Sept.) : Monson. 

Demerara: Chisholm ii, 282; Beane. — Grenada (Summer — 
Autumn): Chisholm i, 138; Trotter ii. 83. — St. Lucia 
(June — July) : Pym, Bally (I) GG. -^ Martinique (June — 
Sept.): Chisholm ii, 119; Davidson (I). — Dominica: Clark. 
— ^ Tortola (July): Chisholm ii, 315; Anderson (I), 21. — 
Santa Cruz : Chisholm ii, 340. — Domingo : Bally (I), 65 ; 
Dalmas 33. — Jamaica (June — August) : Lempriere ii, 55. 
— Bermuda : Barrow, Smart. — Charleston : Ramsay (I), 37 ; 
Johnson (I). — New Orleans : Tliomas (I), 70 ; Chabert (I), 108. 
—New York (July— Dec.) : Bayley (II), Webster i, 316.— 









Wilmington, N. Car. (August — Nov.) : Rosset. — Boston 
(August — Dec.) : Warren (11). — Newbury-port, Mass. (June 
— Oct.): Coffin, Webster i, 318. — Clnitliam, Conn. (Sept.): 
Webster i, 331 ; ii, 344. 

Guayra, Venez. : Humboldt. — Trinidad (April) : Fiedler. — St. 
Lucia : Gillespie 17. — Charleston: Rauisay (I), 37; Jolinsou 
(I).— Norfolk (August— Nov.) : Valentin (I) 87.— Baltimore 
(June — Nov.) : Davidge, Potter 52, New York Med. Repos. 
i, 380. — PbiladelpLia (July — Oct.): Deveze (I), Currie (I), 
Ouviere, 'Proofs;' Harris (I), 'Facts,' 64; Rush (III), 
Pascalis (II), Folwell. — Milesborough, Penns. : Harris (1). 
— Swedesborough, Penhs. : 'Facts' 73. — Providence (Augnsc 
— Sept.) : Wheaton, Bowen (I). — Bristol and other places 
in Rhode Island : Brown (II), Webster, i, 330. 

Domingo: Gilbert 137, 'Facts' 25. — Petersburg, Virg. : 
Erdmann 49. — Baltimore : Davidge 88, Potter 52. — Phila- 
delphia (July— Oct.) : Condie (I, II), ' Facts ; ' "Ourrrie (I, 
IV), Erdmann, 'Proceedings;' Caldwell (I). — Milesborough, 
Penns.: Harris (I). — Germantown, Penns.: Wistar in 
Hosack (III), ' Addit. Facts ' 73. — Swedesborough, Penns. 
ib. — Chester, Penns. : New T. Med. Repos. ii, 196; Erdmann 
47. — Wilmington, Del. (August — Nov.) : Vaughan (I), Erd- 
mann 47, Monro, Tilton. — New-York (August — Nov.) : 
Hardie (I), Hosack (II), M'Knight, Webster i, 334. — 
Bridgetown, Woodbury, Chews, N.-J. (sporadic cases) : 
N. Y. Med. Repos. ii, 302 ; Erdmann 47. — Boston (June 
— Oct.): Brown (I, III), Rand, Webster i, 336; New 
Engl. J, of Med. viii, 380. — New-London, Conn. (August 
— Oct.): Cain, Channing, Holt, Scott, Webster i, 338. — 
Portsmouth, N. Hamp. (July) : Erdmann 46, Webster i, 
337. — Newport, Rh. Is. : Erdmann 47. 

New- Orleans : Chabert (I), 108; Cai*penter 14, — Charleston 
(June to Oct.) : Ramsay (IV). — Wilmington, Washington, 
N. Carol, (only sporadic), Norfolk, Baltimore (August — 
Oct.): New.York Med. Repos. iv, 197, 207. — Philadelphia 
(June — Oct.): Currie (V), Caldwell (I). — Swedesborough 
(sporadic cases) : ' Addit. Facts ' 74. — New- York, Boston, 
Providence, Rh. Isl. (onlysporadic) : N. Y. Med. Repos. 1. c. 
— Hartford, Conn.: Webster i, 347. 

Demerara (August) : Chisholm. — S. Domingo, Santa Cruz : 
Moreau (I), 172. — Surinam: Stille. — New Orleans: Barton 
(I, untrustworthy account). — Charleston (July — Oct.) : 
Ramsay (II).— Savannali (a few cases on board a vessel) : 
Kollock.— Norfolk (July to Oct.) : Hansford, Selden (I).— 
Wilmington (a few cases among sailors) : N. Y. Med. Rep. 
iv, 319. — Baltimore : Moores, Chatard (I). — New York 
(Summer and Autumn) : Seaman (II), N. Y. Med. Repos. 
iv, 207. — Providence (Aug. to Oct.) : Wheaton. 

Martinique : Davidson (II). — St. Martin (July— Nov., seem- 
ingly for the first time): Dickinson (II), 179. — Jamaica 
(August to January) : Doughty 4. — Norfolk (August — 
Oct.) : Selden (II), New York (Summer and Autumn) : 
New York Med. Repos. iv, 207. — New Bedford, Mass. 
(sporadic cases) : Ibid, v, 275. — Block-Island, Rh. Isl., 
(August— Nov.) Willey. 












1813 — 14 



1816— 18 

Caracas: Humboldt ii, 401. — Porto-Cabello : Moreau (I), 156. 
— Cayenne (Sept.) : Leblond 226. — Yera-Cruz (April- 
Got.) : Bally (I) 78. — Tabago : Bonnean, p. 461. — St. Lucia 
(Aug. ff.) : Pugnet 327.— Martinique (Sept. — Dec.) : Moreau 
(I). — Guadeloupe : Lef onion, Rouvier. — Antigua : Mus- 
grave. — Santa Cruz : Keutscli (I). — St. Domingo (April — 
Nov.): Bally (I), 78; Gilbert, Dalmas, Beguerie, Mouille, 
p. 10. — Jamaica: Doughty 16, Pym 184. — Charleston 
(August — Oct.) : Ramsay (V). — Philadelphia (July— Nov.) : 
Currie (VI). — Baltimore: La Roche (II) i, 93. — Wilmington, 
Del. (Sept.) : Vaughan (II).— Boston (^iigust— Oct.) : N. 
T. Med. Repos. vi, 338, in New-Engl. J. of Med. viii, 381. 
— Portsmouth, N Hampsh. (a few cases), ibid. 

Cayenne : Nogen. — Demerara : Frost. — Berbice (January — 
Sept.) : Croissant in Thuessinlv, -p. 1 1 7. — Martinique (the 
whole year): Moreau (I). — Guadeloupe: Bally (I), 81; 
Savart'sy. — Santa Cruz (the whole year) : Keutsch (II). — St. 
Domingo (to Nov.) : Bally (I), 81 ; Fran(,^ois (I). — Jamaica: 
Dancer, Rule. — Alexandria, Virg. (July IF.) : Dick, N. Y. 
Med. Repos. vii, 177. — Baltimore: Ibid.,vi.2 3';. — Philadelphia 
(July to Oct.): Caldwell (II), 17; Rush (III).— New- York 
(July to Oct.) : Ramsay (VI), Mitchell (II), Stringham. 

Vera Cruz : Bally (I), 85. — New Orleans : Carpenter 17, Drake 
ii, 203. — Charleston (July — Oct.) : Ramsay (VII). 

Martinique: Moreau (I) 11 8. — Santa Cruz (May — July): 
Keutsch (III). — Jamaica (Aug. — Jan.) : Doughty 56.— Phila- 
delphia (July ff.): Caldwell. (it); Rush(III),96; ' Addit.Facts' 
85. — New York (June to Nov.) : Miller (I). — Providence (July 
— August) : Wheaton, Bowen (II). — Newhaven : La Roche 
(II) i, 97. — Quebec (untrustworthy account) : Moreau (I). 

Martinique (December — March, 1808): Moreau. (II). — Jamaica 
(Autumn) : Doughty, p. 184. — Charleston (Aug. if.) : Ramsay 
(VIII), Johnson (II). 

Jamaica (Oct. ff.) : Pym, p. 67. — Maria Galante (July — Sept.): 
Mortimer. — St. Marie, Geo. (September ff.) ; Seagrove. — 
Baltimore (August) : Potter 21. 

St. Bartholomew (June — Nov.) : Forstrom. — New Orleans : 
Carpenter 17 ; Drake ii, 203. — Brooklyn, N. J. (July) : 
Gillespie (II). 

New-Orleans: Carpenter 17, Drake ii, 204. — St. Francisville, 
La. : Id., ii, 253. — Pensacola : Id., ii, 227. — Perth Amboy 
(September) : Chisholm (III), Amor. Med. and Philos. 
Regist., iii, 94. 

Bermuda : Barrow, Smart, Jones, p. 204. 

Barbadoes : Thomas (III). 

Barbadoes : Fergnsson (IV). 

Grenada : Dickinson (II), 48. — Guadeloupe : Musgrave (I), 
Vatable, Flory. — Martinique : Rochoux (II) 299. — St. Kitts 
(March ff.) : Birnie. — Barbadoes (September— Feb. 181 7) : 
Ralph, Fergusson (IV), 693. — Antigua (June — Feb. 181 7): 

St. Thomas (September 1816 to January 1818, epidemic): 

Trinidad (August ff.) : McCalie.— New Orleans (July— Oct.) : 
Carpenter 17, Gerardin, j). 56; Gros et Gerardin. — St. Fran- 











cisville: Cai'iicnter 17, Drake ii, 253. — Baton Roiige: Id., 
ii, 250. — Natchez (July— Sept.) : Perlce, Monette (II), Drake 
ii, 263. — Savannah : Daniell (I), 12, Posey. — Charleston 
(July— Nov ) : Dickson (II), Shecut 100. 

-Martinique (July (ff.) : 
^h 350)- — Bermuda (Sept. 


(I).— Demerara : 
Jamaica (May — 

Demerara : Lancet 1867, 11, 200.- 
Lefort (also New T. Med. Repos. 
ff.) : Jones, Barrow, Smart. 

Angostura, Venez, (July — Aug.) : 

Blair (I). — Martinique (Spring) : Lefort.- 
June) : Miller (II).— New Orleans (May— Dec.) : Dupuy, 
Baxter, Fortin, Carpenter 18. — Baton Rouge : Drake ii, 250. 
— Natchez (September to Nov.) : Perlee, Monette, Drake ii, 
265. — Mobile (Juno to Dec): Report (II), Drake ii, 217; 
Lewis (II). — Savannah : Watts, Amer. Med. Record, iii, 
212. — Charleston (August) : Shecut 1. c, Ii'vine. — Bal- 
timore (Jxnie — Sept.): Reese, Revere, 'Letters,' Cha- 
tard (II), Jameson. — Philadelphia (very slight epidemic) : 
Emlen. — New York (August — Oct.) : Drake (II), Pascalis 
(III), Brown (lY), Amer. Med. Record iii, 203 (also very 
limited diffusion). — Boston (August ff.) : Report (I), Ingalis, 
New Engl. Journ. of Med. viii, 380. 

Demerara: Lancet, 1867, ii, 200. — New Orleans (July— Oct.) : 
Carpenter, p. 19, Report (VIII). — Bay of St. Louis, Miss. 
(August) : Merril (I), Report (VII) by Forry, p. 20. — Mobile 
(July to Dec): Report (II). — Savannah (July): Fiirth, 
Daniell (I), Posey, Arnold (II), Waring. — Philadelphia 
(July Nov.) : Jackson (I), Report (IX).— Middletown, 
Conn. : Beck. 

Demerara : Lancet, 1. c — Martinique, Guadeloupe : Kerau- 
dren, p. 14. — Santa Cruz (April — July) : Schlegel. — Tam- 
pico : Heinemann (II). — S. Augustine, Flor. (August — 
Dec.) : Bayley (III), p. 248, according to Francis, Report 
(VII) by Forry, p. 30. — Savannah : Posey. — Wilmington, N. 
Carol. (July ): Hill. — Norfolk (August to Oct.) : Archer. 

St. Vincent: Hunter (II). — New Orleans (September — Nov.) : 
Carpenter, p. 23; Randolpli, Chabert (I, II), Thomas (I). — 
Baton Rouge : Drake ii, 2,r;o. — -Pensacola (July — Nov.) : 
Report (VII) by Forry 35, Drake ii, 228; Townsend (I). — 
New- York (July— Nov.) : Bayley (III), Watters, Hardie 
(II), History (I), Yeates, Townsend (I, II). 

Jamaica (Summer and Aiitumn) : Belcher. — Natchez (August) : 
Drake ii, 266 ; Moneke, p. 66 ; Cartwright (I), Merrill (II), 
Tooley. — Key West (August— Sept.) : Morgan (II), Ticknor. 

Jamaica (August ff.) : Wilson (I). — New Orleans (July ff.) : 
Cai'pentei-, p. 23. — Charleston (Summer) : Simons (I). 

Demerara : Lancet, I.e. — Guadeloupe : Chambolle. — St. 
Thomas (Feb. — May) : Barclay. — • Mobile (September — 
Oct.) : Lewis (I), p. 286.— Natchez (Aug. — Nov.) : Merrill 
(III), Cartwright (I).— Washington (Sept.) : Monette (I). 

Guadeloupe, Martinique (Spring) : Moreau (IV). 

Demerara: Lancet, 1. c — New Orleans (July): Drake ii, 
207; St. Francisville : Id., 2.r;3. — Mobile (August) : Id., 219. 
— Pensacola (Summer) : Id. 230, Report (VII), by Forry. 
58. — Savannah : Posey. — Charleston (August) : Dickson 
(IV), Simons (I), Porter (II), 1855, April. 











1842 — 45 


Demerara : Lancet, 1. c. — Martinique (Octobei- — Jan.) : Moreau 
(Y), Rnfz (II). — New Orleans (June ff.): Drake ii, 207. 
— Memphis (September — Nov.) : Id., 283. 

Havana, Jamaica (April — July) : Moreau (VI). — New 
Orleans (July ff.) : Id., Monett (IV). — Plaquemines 
(Aiiffust) : Drake ii, 249. — Francisville (Sept.): Id., 253. 

— Baton Rouge : Carpenter, p. 26. — Natchez : Monette 
(IV), Car]3enter, 1. c, Drake ii, 273. — Mobile : Id., 220, 
Lewis (I), 1. c. — Key West (June — August) : Dupre. 

Demerara : Lancet, 1. c. 

St. Thomas (Feb. — May) : Dons. — New Orleans (July — Nov.) : 
Barton (I), Han-is (II). 

New Orleans (August) : Drake ii, 208. — Pensacola (August : 
Id., 232 ; Barrington. 

Surinam (Dec. ff.) : Fraser (I), Pop, Dumortier (I). — Antigua 
(Sept. — Dec.) : Furlong (I), Nicholson. 

Tampico, Mex. (Sept. — Nov.) : Goupilleau. 

Demerara, Surinam (May — July) : Fraser (I), Blair (I). — 
Havana : Maes. — New Orleans (July — Oct.) : Thomas (II). 
— Opelousas (Oct.— Nov.) : Carpenter, p. 52 ; Cooke (I).— 
Natchez (Sept. to Nov.) : Monette (II), p. 7.^5 ; Hogg. — 
Mobile (Sept.— Nov.) : Lewis (I), 287; Nott (II), Drake ii, 
220. ■ — • Bermuda : Bari'ow, Smart. 

Demerara : Blair (I), Lancet, 1. c. — Trinidad (June). — Gua- 
deloupe (July). — Martinique (Sept. — Oct., 1839) : Catel, 
Rufz (I, II). — Dominica (April — June) : Imray (I). 

— Charleston (July to Oct.) : Wurdeman, Strobel, Hume 
(II), Simmons (II), Johnson (I). 

Demerara: 11. cc. — St. Vincent: Hunter (II). — Antigua 
(June) : Nicholson. — Galveston, Houston (Sept. — Nov.) : 
Smith (III, IV), Drake ii, 237. — New Orleans (August) : 
Carpenter, p. 27, Lemoine, Journ. de la Soc. med. de la 
New Orleans, 1839, Nr. 4. — Franklin, New Iberia (Sept. — ■ 
Nov.): Carpenter, p. 27; 28, Monette (III), p. in, 113; 
Drake, ii, 238, 241. — Opelousas (September) : Carpenter, 
p. 59, Cooke (I). — Alexandria (September) : Monette (III), 
1. c. — Natchitochez, Donaldsonville, Port Hudson, Waterloo, 
St. Francisville, Fort Adams (Sept) : Monette (III), p. 108, 
9;";, 98 ; Carpenter, p. 27 ; Drake ii, 254, 262. — Natchez 
(August) : Id., ii, 275. — Bay of Biloxi: Monette (III), 117. 

— Slobile (August— Oct.) : Lewis (I) 289. — Pensacola 
(Sept.) : Carpenter, p. 27 ; Drake ii, 233. — Augusta (July 
ff.): Robertson, Strobel, p. 187. — Charleston (June if.): 
Strobel, 1. c, Hume (II), Simons (II). 

Demerara, Surinam : 11. cc, Dumortier (I).— Curasao (Oct. — 
Nov.) : Schorrenberg. Hommel. — Dominica (June — Sept.) : 
Imray (II).— New Orleans (August — Oct.) : Carpenter 29, 
Thomas (V), Barton (III). — Vicksburg (August— Nov.) : 
Drake ii, 281. — Pensacola (August): Hulse, Laurison. — 
Key West (June to August) : Dupre. 

Demerara: Blair (I). 

Antigua (Sept. — Nov.): Nicholson.— New Orleans (July): 
Carpenter, 29, 30. — Opelousas: Id., Cooke (I). — Mobile 
(August) : Lewis (I), 289 ; Drake ii, 222. 

Galveston, Houston : Smith (IV).— New Orleans (July), St. 










Francisvillc (August), Baton Rouge (October) : Carpenter, 
p. 30, Drake ii, 251, 255. — Rodney, Miss. (September) : Id., 
ii, 278 ; Williams (II). — Mobile (August — Dec.) : Lewis (I), 
290, — Charleston (September) : Hume (II). — New York : v. 
Hohenberg. — Bermuda (July — Dec.) : Report (VI), 1853, 
176; Laird, Smart, Barrow. 

Guadeloupe : Carpentin, 45. — New Orleans : N. O. Med. J., i, 
Nr. 4.— Woodville (July— Sept.) : Valctti, Stone (H).— 
Mobile : N. O. Med. J., 1. c. 

Tamaulipas (Mexico) : Heinemann (II). 

Barbadoes (Oct. — Dec, 48) : Davy. — Vera Cruz (May S.) und 
Tamaulipas : Porter (I), Heinemann (II). — Galveston, Hous- 
ton : Smith (IV), Bracht, McCi'aven. — New Orleans (July 
— Oct.) : Fenner (IV), Thomas (IV). — Covington, La. : 
Gilpin (II). — Rodney, Miss. : Williams (III). — Vicksburg : 
Hicks, Macgruder. — Natchez : Cartwright (II). — Mobile : 
Lewis (I), Nott (III). — Puscagoula (July — Nov.) : Porter 

New Orleans : Fenner (V). — Natcbez : Stone (III). — New 
York (September) : Bodinier. 

Antigua (Summer) : Nicholson. — New Orleans (July — Dec.) : 
Fenner, South. Med. Rep., i, 114. — Charleston (August — 
Nov.) Hume (IV), Simons (II). 

Cayenne (and next year) : Kerhuel, Genouves. — New Orleans 
(July— Oct.) : Fenner (VI), 

Demerara (from Dec. 51 to Dec. 53) : Lancet, 1. c, Blair (II). 
— Paramaribo, Sur. (1851): Pop. 

Charleston (August — Nov.) : Porter (II), Simons (II). 

Antilles in universal diffusion : St. Thomas (starting point 
of the epidemic, August — Jan.) : Hildige, Archambault, 
' Aarsberetning,' 1853, i, 35, 36. — Domingo: Ibid., 11. cc. — 
Guadeloupe (Dec. ff.) : Dutroulau (III), Carpentin, 1. c. — 
Martinique : Encognore, Rufz (II).— Santa Cruz (Oct. — 
April): 'Aarsberetning,' 1. c. — CJura^ao (Dec. to 1855 con- 
tinuously) : Pop, Nederl. Tijdschr. voor Geneesk, 1858, 223. — 
Cuba, Porto-Rico, Dominica, St. Lucia. Barbadoes: Hildige. 

Coast of Mexico (general diffusion) : La Roche ii, 623 ; also 
in the Antilles : Ibid. — Antigua (May) : Nicholson, Furlong 
(II). — Barbadoes : Teevan. — St. Thomas (April — August) : 
' Aarsberetning,' 1856, p. 68. — Gulf Coast of N. America and 
up the Mississippi Valley, in general prevalence : La 
Roche, 1. c. — New Orleans (May — Oct.) : Fenner (I), Mercier, 
Dowler (I), N. Orleans Med. J., 1853 Sept. Barton (II).— 
Madisonville, Mandeville, Louisbourg, Covington, Baton 
Rouge, Port Hudson, St. Francisville, Bayou Sara : Dowler 
(I). — Franklin, La. : Lyman. — Washington, La. : Cooke (II). 
— Arkansas in several localities on the Mississippi : Dowler 
(I). — Natchez : New Orleans Med. News and Gaz., 1855, 
Oct. I. — Clinton, Jackson, Grand Gulf, Yazoo, Vicksburg, 
Miss. : Dowler, McAllister. — Memphis, Tenn. : Smith 
(VIII).— Mobile : Anderson (III). Nott (IV), Ketchum.— 
Selma, Ala. : Marks. — Florida (various points on the coast) : 
Dowler, — Brandywine, Del. (July — Sept.) : Bush. — Phila- 
delphia (July — Oct.) : Jewell (I). Bache, La Roche (I, II) i, 
no. — Bermuda (August to Nov.) : Barrow, Milroy, Smart. 













Surinam : Pop, Dumortier (I). — Cura9ao (Febr.) : Landre. — 
Antigua: Morehead. — Galveston, New Orleans (July IF.): 
Med. News. — Mobile (August — Nov.): Ketchum. — Mont- 
gomery, Ala., St. Marie, Darien, Augiista, Geo. : Med. 
News. — Savannah, Geo. : Posey, Hume (V), MacKall, Arnold 
(II). — Charleston: Cain, Chisholm, Hume (III). 

Cayenne (May ff.) : Kerhuel. — Martinique (Oct. — August, 
1857): Ballot, Chapuis, Encognerc, Pellarin. — St. Thomas 
(Jan. — Nov.), Santa Cruz (April if.) : ' Aarsberetning,' 1856, 
71. — Domingo : Ai'chambault. — Havana : Ramon. — New 
Orleans : Med. News. — Natchez : New Orl. Med. News and 
Gaz., 1855, Oct. I. — Vicksburg, Yazoo, Cooper's Well, Jack- 
son, Clinton, and other places in Mississippi, Memphis, 
Tenn. : Med. News.— Portsmouth and Norfolk (July— Oct.) : 
Bryant, Fenner (II), Williman, Report (III), Warren (III). 

Cayenne (Jan. ff.) : Kerhuel. — Martinique, Guadeloupe, St. 
Thomas: 'Aarsberetning,' i8,';7,297. — Jamaica : Lawson, Brit. 
Army Reports for 1867, ix, 216. — New Orleans (July ff.) : 
New Orl. Med. Times, 1856, Sept.— Charleston (July— Sept.) : 
Dawson, Chariest. Med. Journ., 1856, Dec, 845, Hume (YI). 
—New York (July— Sept.) : Harris (IV), Med. News, 1856, 
144, and N. York Journ. of Med., 1856, Sept., Buckley.— 
Long Island (July — Aug.) : Buckley, Rothe. — Bermuda 
(July — Oct.) : Barrow, Milroy, Smart. 

Martinique : Encognere. — Guadeloupe : Batby-Berquin. — St. 
Thomas (April— July), Santa Cruz (Sept. — Nov.): 'Aarsbe- 
retning,' 1858, 429. — St. Domingo : Archambault. — New 
Orleans: Mercier, 468.— Charleston (August — Sept.): Kin- 
loch, Hume (VIII).— Jacksonville, Flor. (Oct.) : Porcher. 

Panama. — Antigua (Dec. ff.).— St. Thomas (April, Nov. — Dec.) : 
'Aarsberetning,' 1859,436. — Trinidad (Sept.). — Matamoros : 
Heinemann (II). — Galveston. — Brownsville, Tex. (August — 
Oct.) : Watson. — New Orleans (June — Oct.) : Faget, 32, 
Mercier, 475, 567. — Mobile, Savannah. — Charleston (Sept. 
ff.): Report (IV), Chariest. Med. Journ., 1858, Nov., 841, 
Byrne, U.S. Army Reports, i860, 122. — Philadelphia (Sum- 
mer, a few imported cases) : Jewell (II). 

Panama.— Trinidad.— St.Thomas(Oct.— Dec): 'Aarsberetning,' 
i860, 409.— Curasao (Nov.— Feb., 60) : Nederl. Tijdschr. voor 
Geueesk, i860, 127, 256.— New Orleans (Sept. ff.); N. Orl. 
Med. News and Hosp. Gaz., 1859, ^^^- — Texas : Dewier 

Honduras (Belize) : Hamilton. — Cuba, Jamaica, Domingo, 
Martinique, and others of the Windward Islands. 

Cartagena. — Nassau (Bahama). — Martiniqiie. — St. Thomas. — 
Halifax, Nova Scotia (July— Sept.) : Slayter, Mauger. 

Demerara (continuously from May, 1861 to 1866 mostly on 
board ship): Lancet, 1867, ii, 200, and in Brit. Army 
Reports for 1868, x, 69. 

Vera Cruz (March— Sept.) : Crouillebois, Bouffier, Legris, 
Buez in Gaz. Med. de Paris, 1862, 440.— Cuba.— Tortuga.— 
St. Lucia. — Barbadoes: McGregor in Brit. Army Reports 
for 1864, vi, 256. — Bahama: lb., 255.— Louisiana (several 
places on the coast).— Key West (July) : Horner, Med. 
History of the Rebellion, Philad., 1865, p. 113.— Pensacola. 











1868 — 70 







— Soutli Carolina (several places on the ccast), Hilton Head, 
S. Carol. (August) : History of the Rebellion, ib. — Wilming- 
ton, N. Car. 

Vera Cruz, Matamoros, Tuxpam, Tampico, Mex. : Jaspard, 
Heinemann (II).— Nassau, Bah.— Pensacola (July— May, 
1864): Gibbs. 

Bermuda (June — Dec.) : Barrow, Report (V). — Newbern, N. 
Carol. (Summer) : History, 1. c. 

Vera Cruz : MoufHoy, Schmidtlein. 

Guadeloupe.— Domingo : Dupont, p. 55.— Campeche (Mex.) : 
Heinemann (II). 

Cayenne.— Paramaribo : Gori, Nederl. Tijdschr. voor Geneesk, 

1866, i, 589. 

Jamaica: Donnet, Arch, de Med. nav., 1870, July, 'August ; 
Brit. Army Rep. for 1867, ix, 224.— St. Thomas: Miller 

Panama (Pacif. Coast).— Cuba (Summer) : Dunlop. — Barbadoes 
and others of the Antilles: Med. News. — Matamoros : Heine- 
mann (II). — Texas (Autumn) in Galveston, Corpus Christi, 
Indianola, Lavacca, Lagrange, Victoria, Huntsville, Hemp- 
stead, Mellican, Alley ton, Navasola, &c. : Kearney, New 
York Med. Record, 1867, Oct., 373; Heard in Transact, of 
the Amer. Med. Assoc, xix, Philad., 1868. — New Orleans 
(June— Nov.) : Stone (I), Schmidt, New Orl. Med. Journ., 

1867, Nov. ; Chaille, ib., 1870, Jan. — New Iberia, La. — Mem- 
phis: Ma] lory. — Vicksburg.— Mobile.— Key West (August 
If.) : Dimlop, Thompson. — Pensacola : Philad. Med. and 
Surg. Reporter, 1868, March, 227. 

Vera Cruz : Lancet, 1868, Aug., 268. 

Manzanillo, Mex.: Philad. Reporter, 1. c. — Nicaragua, San 
Salvador: Guzman, Gonzalez in France Med., 1869, No. 46. 
—St. Kitts : Munro. 

Martinique: Rufz (II), Bakewell, in Lancet, 1869, Dec, 794. 

Cuba (Havanna, Matanzas, Cienfuegos, Sagua, &c.), Philad. 
Reporter, 1. c, Poggio in Siglo Medico (Med. Times and 
Gaz., 1869, Oct., 516), Sullivan in Med. Times and Gaz., 1871, 
March, 304 —Guadeloupe: Rufz (II), Batby-Berquin, GriflFon 
du Bellay, Carpentin. 

Caracas, Venezuela. — Nassau, Bah. — Trinidad: Bakewell, 

Governor's Island, N. York : Sternberg. 

Charleston : Porcher in Transact, of the South Carolina Med. 
Assoc, for 1872, p. 3." 

Southern States (in general diffusion) : Texas (Marshall, Cal- 
vert, &c.). — New Orleans: Jones (II). — Shreveport, La. : Jones 
(III), Marsh. — Memphis, Tenn. : Mallory.— Montgomery 
and other places in Alabama : Miehel in Transact, of the 
State Alabama Med. Association for 1874. — Vicksburg : 
Transact, of the Mississippi State Med. Assoc, for 1874. — 
Bainbridge, Geo., &c. 

Pensacola, Flor. 

Mexico (severe epidemic) : Heinemann (II). 

Cordoba, Mex. : Heinemann (II). — Savannah, Brunswick, Geo.: 
Woodhull, White, Purse, Report (IX). — Baltimore. 

Jamaica: Med. Times and Gaz., 1877, Sept., 340. — Cayenne: 




Crevaux. — Mexico (severe epidemic) : Heinemann (II). — 

Jacksonville. Flor. 
Mexico (severe epidemic) : Id. — Southern States of the Union 

in wide diffusion : Jones (IV), Bayley (II), numerous 

accounts in New York Med. Record and Philad. Med. and 

Surg. Reporter, 1878. 
Memphis : Thornton. 

Table according to Latitude of the Yelloiv Fever Epidemics in 
tlie West Indies, N. America, C. America^ and the Owlf 
Coast of S. America} 

Guiana : 

*Cayenne (4°56 N.) 1763—65, 1791, 1802, 1803, 1850, 1855, 1856, 

1 866, 1877, 
*Surinam (5°5o N.) 1760, 1793, iSoo, 1803, 1835, 1837, 1841, 1851, 

1854, 1866. 
*Demerara (6°49 N.) 1793—96, 1800, 1803, 1818, 1819, 1820, 1821, 
1825, 1827, 1828, 1831, 1837—39, 1841—45, 1851—53, 1861—66. 
Yenezuela : 

fAngostura (8°8 N.) 18 19. 

*Giiayra, Caracas (10^30 N.) 1693, 1696, 1793, 1797, 1802, 1869. 
*Porto Cabello (io°29 N.) 1802. 
New Granada : 

*Cartagena (io°25 N.) 1740, 1861. 
Central America : 

*Panama (8^57) 1740, 1858, 1859, 1867. 
*Portobelo (9°24) 1726, 1729, 1740, 1793, i860, 1866, 1867. 
*Nicaragua(io°— 15°) 1868. 
*San Salvador ( 1 3°— 1 4°) 1 868. 
*Belize (Honduras) (17*^30) i860. 
Antilles in wide diffusion: 1699, i860, 1867. 

*Trinidad (io°2o) 1793, 1797, 1817, 1838, 1858, 1869. 

*Tabago (ii°2o) 1793, 1802. 

*Grenada (i2°2) 1770, 1791, 1793 — g6, 1816. 

*Curacoa (i2°6) 1751, 1760, 1841, 1852 — 54, 1859. 

*St. Vincent (13° 10) 1793, 1795, 1822, 1839. 

*Barbadoes (i3°io) 1647, 1690, 1694 — 95, 1699, 1715, 1721 — 24, 

1733-39. 1793. 1813— 16, 1847, 1852—53, 1862, 1867. 
*St. Lucia (i3°5o) 1665, 1767, 1796 — 97, 1802, 1852—53, 1862. 
*Martinique (i4°3o) 1688 — 90, 1693 — 94, 1696 — 97, 1699, ^703' 
1705—6, 1750, 1770—72, 1793—96, 1801— 3, 1805, 1807, 1816, 
1 818— 19, 1821, 1826—28, 1838, 1852—53. 1855—57, i860, 
1 86 1, 1868—69. 
*Dominica (i5°i8) 1793—94, 1796, 1838, 1841, 1852—53. 
*Maria Galante (16°) 1808. 

*Guadeloupe (i6°io) 1635 — 49, 1699, 1703, 1795. 1802 — 3, 1816, 1821, 
1825—26, 1838, 1844, 1852—53. 1856—57, 1S65. 1868—70. 

' * Indicates places on the coast, f Places on large navigable rivers. % Places 
in the interior ou small rivers or at a distance from rivers. 


*Antigxia(i7°8) 1729, 1754, 1756, 1765—66, 1793, 1S02, 1S16, 1835, 

1839, 1S42, 1S49, 1853—54, 1858. 
*St. Kitts (i7°i7) 1648, 1652, 1699, 1793, 1816, 1868. 
*Saiita Cruz (i7°44) 1690, 1793—94, 1796, 1800, 1802 — 3, 1805, 1821, 

1852— 53> 1S55, 1857. 
*St. Bavtlioiomew (i7°55) 1809. 
*St. Martin (i8°5) 1801. 
*St. Thomas (18^20) 1793—95. 1S16— 18, 1825, 1833, 1852—53, 

1855 — 59, 1861, 1866—67. 
*Tortola (18^27) 1796. 
*Puerto Rico (17°— 18°) 1852—53. 
*San Domingo (17° — 19°) 1656, 1690, 1696 — 97, 1699, 1705, 1731, 

1733—37, 1740—41, 1743—46, 17S1— 82, 1793, 1795—96, 1798, 

1800, 1802, 1803, 1852—53, 1S55, 1857, i860. 1862, 1865. 
*Jamaica (17°- 18") 1655, 1671, 1741 — 42, 1780, 1793 — 96, 1801— 3, 

1805, 1807—8, 1 819, 1823, 1824, 1829, 1856, i860, 1866—68, 

*Cuba(23°9) 1762, 1780—82, 1794, 1S29, 1837, 1852—53, 1855, i860,- 

1862, 1867 — 70. 
*Nassau (Bahamas) (25^4) 1861, 1862, 1863, 1869. 
Mexico : 

*Yera Cruz (i9°ii) 1699, 1725, 1740, 1794, 1802, 1804, 1847, 1853, 

1862—65, 1868, 1875, 1877, 1878. 
*Manzanino (i9°i2) 1868. 
*Campeche (i9°5i) 1865, 1877. 
*Tuxpam (22°io) 1863, 1875, 1877. 
*Tampico (22°i5) 1821, 1836, 1845, 1847, 1853, 1864. 
*Papantla (22°i5) 1877. 
*Matamoros (2o°25) 1858, 1S63, 1867. 
+Cordoba ( 18^50) 1876. 
North America : 

Texas, 1S59, 1867 (in many inland places) 1873 : 

*Galveston (2o°i8) 1839, 1843, 1847, 1854, 1858, 1859, 1867. 

fHouston (30*^) 1839, 1843, 1847, 1859, '867. 

*Corpus Christi (2 7^25 ) 1859, 1867. 

flndianola (29°2o) 1859, 1867. 

jLagrange (3o''25) 1859, 1867. 

fBrownsville (25-'54) 1858. 
Louisiana (29° — 3i°6o) in wide diffusion, 1862, 1873: 

fNew Orleans, 1791, 1796, 1799, 1800, 1804, 1809, 181 1, 181 7, 
1819, 1820, 1822, 1824, 1S27— 29, 1833—34, i837» 1839^ 
1841—44, 1847—50, 1853—59, 1867, 1873, 1878. 

fPlaquemines, 1829, 1878. 

*Madisonville, 1853. . 

fLouisburg, 1853. 

fMandeville, 1853. 

fCovington, 1847, 1853. 

fFranklin, 1839, 153. 

fNew Iberia, 1839. 1867. 

fDonaldsonville, 182. 

fPort Hudson, 1829, 1853. 

fWaterloo, 1829. 

fBaton Rouge, 1817, 1819, 1822. 1829, 1843, 1853, 1878. 

*Port Eads, 1878. 

JMorgan, 1878. 

JOpelousas, 1837, 1839, 1S42. 

fSt. Francisville, 181 1, 1817, 1S27, 1829, 1839, 1843, 1853. 


fAlexandria, 1839. 

fNatcbitochez, 1839. 

tSlircvepovt, 1873. 
t Arkansas (33°— 34°) at several places on tlie Mississippi, 1853. 
Mississippi (30°28 — 32°r;o) : 

*Slneldsborongh, 1820, 1829. 

*Biloxi, 1702, 1839. 

*Pascagoula, 1847. 

*Port Gibson, 1878. 

fPort Adams, 1839, 1853. 

JWoodville, 1844. 

fRodney, 1843, 1847. . „ o 

tNatchez, 181 7, 18 19, 1823, 1825, 1829, 1837, 1839, 1847—48, 

1853- 1855. 

JWasbington, 1825. 

tGrand Gulf, 1853. 

t Jackson, 1853, 1855. 

fCliuton, 1853, 1855. 

fVicksburg, 1841, 1847, 1853, 1855, 1867, 1873, 1878. 

fYazoo, 1853, 1855. 
Tgtiugssgg * 

fMempliis (35°5) 1828, 1853, 1855, 1867, 1873, 1878, 1879. 

fBrownsville, 1878. 

tChattanooga, 1878. 
Alabama (30^4 1 — 32°45) : 

*Mobile, 1765, 1819, 1820, 1825, 1827, 1829, 1837, 1839, 1842—44, 
1847, 1853—54, 1858, 1867, 1878. 

fMontgomery, 1854, 1873. 

fSelma, 1853. 
Florida (24°32 — 30°24) 1853, ^^ many places on tte coast, 

*Pensacola (30°24) 1765, 181 1, 1822, 1827, 1834, 1839, 1841, 1862, 
1863, 1867, 1874. 

*Key West (24^32) 1823, 1829, 1841, 1862, 1867. 

*St. Augustine (29°6o) 1821, 1841. 

t Jacksonville (30"") 1857, 1877. 

Georgia (30°75— 33°45) = 

fSt. Mary, 1808, 1854. 

*Daricn, 1854. 

*Brunswick, 1876. 

*Savannali, iSoo, 181 7, 1820—21, 1827, 1854, 1858, 1876. 

t Augusta, 1839, 1854- 

*Bainbridge, 1873. 
South Carolina : 

*Hilton Head (32°io) 1862. 

*Cliarleston (32'=46) 1693, 1699, 1700, 1728, 1732, 1739, I745. 

1748, 1792, 1794, 1796—97, 1799, 1800, 1802, 1804, 1807, 

1817, 1819, 1824, 1827, 1838—39, 1843, 1849, 1852, 1854, 

1856—58, 1862, 1 87 1. 

Bermudas (32°) 1699, 1779—80, 1796, 1812, 1S18, 1837, 1843, 1853, 

1S56, 1864. 
North Carolina : 

*Wilmington (34°! i) 1796, 1799, 1800, 1821, 1862. 

*Newbern (35°2o) 1864. 

*Wasliington (35°4o) 1 799. 
Virginia : 

*Norfolk (36"5o) 1737, 1741—42, i795. i797, i799» 1800— i, 1821, 


fPetersbvirg (37°i3) 1798. 

^Alexandria (38^^49) 1803. 
Maryland and Delaware : 

*Baltimore (39°i7) 1783, 1794, 1797 — 1800, 1802 — 3, 1808, 
1819 — 22, 1876. 

*Wilmington (39°4i) 1798, 1802. 

fBrandywine (39°43) 1853. 
Pennsylvania (39°5o — 40°i5): 

*Marcus Hook, 1798. 

fPhiladelpbia, 1693, 1699, 1741, 1747, 1762, 1793—94, 1797—99' 
1802—5, 1S19— 20, 1853, 1858. 

fCliester, 1798. 

fSwedesborough, 1797 — 99. 

fMilesboroiigh, 1797 — 98. 

fGermantown, 1798. 
New Jersey (39°40 — 40^45) : 

*Bridgetovvn, 1798. 

fCbews, 1798. 

fWoodbury, 1798. 

*Pertb Amboy, 181 1. 
New York (40°4]— 40*^42) : 

*New York, 1693, 1702, 1743, 1745, 1791, 1794—96, 1798— 1801, 
1803, 1805, 1819, 1822, 1843, 1848, 1856, 1870. 

*Brooklyn, 1809. 

*Long Island, 1 856. 
Connecticut (41°! 8 — 4i°45) : 

*New Haven, 1743, 1794, 1805. 

*New London, 1795, 1798. 

fMiddletown, 1820. 

fCbatbam, 1796. 

fHartford, 1799. 
Rbode Island (41°! 3 — 4i°49) '• 

*Block Island, 1801. 

*Newport, 1798. 

*Bristol, 1797. 

*Providence, 1797, 1799, 1800, 1805. 
Massacbusetts (41 '^38 — 42°48) : 

*New Bedford, 1801. 

*Boston, 1796, 1798 — gg, 1802, 1819. 

*Newburyport, 1796. 
New Hampsbire : 

*Portsnioutb (43°4), 1798, 1802. 
Canada : 

tQuebec (46°5o) 1805: 
Nova kjcotia : 

*Halifax (44°26) 1861. 

On the mainland of Soutli America yellow fever has become 
widely diffused only since the sixth decade of the present 
century. Whether the information about malignant sickness 
in Pernambuco in 1640, 1687, 1710, and 1780, relates, as 
McKinlay believes, to yellow fever, is at least doubtful / still 

' The description given by Piso (' De mediclna Brasil.,' lib. i, p. 13; lib. ii, 
p. 15) in the middle of the 17th century of a pernicious fever observed in 


less credit is duo tlio notion tliat tlie epidemic of 1(347 ^^ 
Santiago^ and that of 1781 in Lima" were yellow fever. Thus 
during- the whole of the past, up to the year 1850, there have 
been only two epidemics observed on South American soil that 
may be designated with certainty as yellowfever. Both of these 
happened at Guayaquil; the first in 1740, concerning which 
an importation of the disease from outside is expressly men- 
tioned -^ and the second in 1842, which can in like manner be 
proved to have been introduced by strangers who had come 
from New Orleans by way of Panama.^ 

The general outbreak of yellow fever in Brazil dates from the end of 
1849 f in October the sickness appeared in Bahia, having been imported 
either from New Orleans or Havana ; it soon attained the extent of 
an epidemic, and from Bahia, Rio Janiero was infected in December, 
Pernambuco in Febriiary, i8r,o, and Para. Alagoes, and Parahiba, 
almost at the same time, while Santa Catariua and Santos were 
attacked in March. In the summer of the following year the disease 
first showed itself in St. Louis de Maranhao, and in June it was at 
Ceara, so that by that time the whole coast and the country for several 
miles inland was overrun by the pestilence. In 1852-54 the disease was 
prevalent in epidemic form at isolated points only, in 1855 it again broke 
out over a wide area, and it spread in the following year along the 
Amazon far into the interior of the country.^ Since then it has never 
left Brazil altogether ; its years of special severity have been i859-6o» 
1862, 1S69-70, 1872-73, and 1875-77.' 

From Brazil yellow fever came first to Peru in 1854, and it 
was probably brought by a vessel with German emigrants. The 

Brazil does not suit yellow fever j and as regards the epidemic described by 
Ferreyra da Eosa (' Trattado da coustitui9ao pestilencial de Pernambuco,' 
Lisboa, 1694), wbicb was prevalent in Pernambuco from 1687 to i(h)4, Sigaud 
(p. 116) expressly states that it had nothing in common with yellow fever. 

' Frezier, ' Ilelat. du Voyage dans le Mcr du Sud, &c.,' Paris, 171O, p. 41. 

- Leblond, p. 190. 

3 Ulloa, p. 149. 

' Celle, p. 80; Smith (VII), p. 244. 

* See McWilliani, Balcer, Paterson, M'Klnlay, Bollinger, Wuchercr, Lalle- 
mant, and especially De Moussy, ' Description gcogr. et statist, de la Confedera- 
tion Argentine.' 

^ Lallemant, p. 120 ff. 

' Rey, following the numerous reports of Brazilian physicians. 

8 See Eysaguirre. 1'he statements of Smith (I and V) about the yellow 
fever iu Peru are to be received with caution, inasmuch as that author has 
confounded the disease with the dengue which was prevalent there at the same 
time, as well as with a febrile sickness which occurred afterwards in the 


disease appeared first in the port of CallaOj sliortly thereafter 
in Lima. In the years following it spread over a great part 
of the Peruvian coast, without, however, penetrating into the 
mountainous regions of the interior. From the first appear- 
ance of the sickness in 1854 down to i868-6g, when it raged 
Avith unusual severity,^ yellow fever had never been absent 
from Peru." Up to the present time Chili has remained free 
from yellow fever ; on the other hand, since 1857 the disease 
has been several times introduced from Brazil into the States 
of the River Plate, first into Monte Video^ in 1857, next year 
into Buenos Ayres,'* in 1869 to Asuncion, where it was preva- 
lent also the year after,^ further into Corrientes^ and Buenos 
Ayres^ in 1870, and again into Monte Video from Pernam- 
buco in 1872.^ Since that date yellow fever does not appear 
to have visited those regions. 

A striking^ contrast to the large area of distribution of 
yellow fever in the Western Hemisphere is presented by the 
very limited occurrence of the disease in the Old World, where, 
if we disregard the quite isolated outbreaks in the South- 
West of Europe, it is met with at one point only, viz. the 
West Coast of Africa. The records of physicians and tra- 
vellers in that region in former centuries are too scanty and 
unreliable to enable us to decide how soon yellow fever 
showed itself after the first settlements of Eui'opeans on the 
coast. The earliest trustworthy information^ is to be found 
in the account by Schotte of the epidemic of yellow fever at 
St. Louis (Senegal) in 1778, an epidemic which, like all the 
later ones at the same place, could be traced to an importa- 
tion of the disease from Sierra Leone. The latter strip of 

mouutainous parts of the country, and was proved by Macedo (' Gaz. meJ. de 
Lima,' 1858, No. 48) and others to have been not yellow fever, but typhus. 

^ Account in the ' Lancet,' 1869, March, p. 446. 

' Boilleau, in the ' Compt rend.,' 1869, Ixix, No. 18. 

^ Brunei, ' Mantegazza,' i, p. 10, Scrivener (II). 

■* Scrivener (I). 

5 Hiron. 

6 Id. 

7 Id., Scrivener (I), Leeson. 
^ Scrivener (II), Brendcl. 

3 Busto y Blanco mentions two epidemics of yellow fever in the Canary 
Island, 1701 and 1771, introduced, however, in both cases, as we are told, from 
the West Indies. 



coast appears, indeed, to be the headquarters of the disease, 
and the starting-point of its epidemic inroads into the terri- 
tories lying to the north and south, as well as into the West 
African Islands. In the two following tables I have put 
together, in chronological order and according] to latitude 
respectively, the yellow fever epidemics that are known to 
have occurred over the whole of the territory here mentioned 
since the beginning of this century. 

Clironological survey of yelloio fever ejnderiiics on the West 
Coast of Africa and the West African Islands. 



1829 — 30 












Teneriffe (introduced from Cadiz) : Busto y Blanco (I), Ver- 

240). — Congo Coast : 

Sierra Leone : Bancroft (' Sequel,' p. 

Morcau (XIV). 
Sierra Leone : McDiarmid, p. 448 ; Boyle, p. 20 x ; Bryson (I), 

P- 35. Gore, p. 405. — Ascension: Burnett (I), Fergusson 

(11),' 840. 
Sierra Leone : Boyle, p. 201 ; Gore, p. 407. 
jSierra Leone : Boyle. Bryson, McDiarmid, 11. cc. ; Gore, p. 408. 
Senegambia: Thevenot, p. 254 ; Francois (II), Chevee. 
Sierra Leone: Bryson (I), p. 6r'y; McDiarmid, p. 444, Clai-ke, 

Gore, p. 409. 
Senegambia: Fergusson (III), p. 841; Cedont.— Ascension : 

same references as under 1823. 
Fernando Po : Bryson (I), p. 68. 

Sierra Leone : Bryson (I), p. 156; Clarke, Gore. p. 411. 
Boa Vista (Cape Verd Islands) : McWilliam. King, Bryson 

(I), p. 96. 
Canary Islands (imported from America) : Busto y Blanco. 

[ Gold Coast (Grand Bassam, Dabon) : Sarrouille. 

Senegambia (Goree). 

Sien-a Leone: Clarke, Gore, p. 412.— Senegambia (Goree, 
Batburst) : Cedont. 

Gambia (Macartby's Island).— Congo Coast (Loanda, Angola). 

Sierra Leone. — Gold Coast : Sarrouille. — Benin Coast (Cala- 
bar) : Account in 'Transact. Lond. Epidemiol. Soc.,' i, 387. 
— Congo Coast: Ref., ib. — Fernando Po. — Cape Verd 
Islands. — Teneriffe and Palmas (Canary Islands) : Busto y 

Sierra Leone (Lagos). 

Sierra Leone: Gore, p. 413 ; Mackay.— Congo Coast (Loanda) : 

Sierra Leone : 11. cc. — Senegambia (Goree, Batburst) : Cedont. 

Senegambia (St. Louis) : Carbonnel, p. 30. 

Sierra Leone. — Senegambia. — Cape Verd Islands (St. Jago, 
Brava) : De Silva. 

Sierra Leone (?)— Senegambia : Crcvaux. 


Cliorofjra'phic survey of the ejndemics of yelloiu fever on the 
West Coast of Africa and the West African Islands. 

Sierra Leone: 1816, 1823, 1825, 1829—30, 1837—39, 1845—47,1859, 
1862, 1864, 1865—66, 1868, 1878 (?). 

Senegambia: 1778, 1830, 1837, 1858, 1859, i860, 1866, 1867, 1868, 

Gold Coast: 1852, 1857, 18^2. 

Benin Coast: 1862. 

Congo Coast : 18 16, i860, 1862, 1865. 

Ascension : 1823, 1837. 

Fernando Po: 1839,1862. 

Cape Verd Islands : 1845, 1862, 1868. 

Canary Islands : 1701; 1771, 1810, 1846,1862. 

On tlio north coast of Africa, yellow fovor has been 
observed only once, in 1804, on the small island containing 
the Spanish fortress of Alhuzemas, lying off the coast of 
Morocco, whither it had been imported from Catalonia.^ 

The farthest point hitherto to which yellow fever has 
extended its epidemic range is the South West of Europe ; 
and if we set aside an occurrence of it once (1694) at Koche- 
fort (where the fever might be regarded as pernicious mala- 
rial"), and once (1804) at Leghorn (whither it was imported 
from Cadiz^), its European area is limited to the south-west 
coast of the Iberian peninsula and to Majorca. 

TTie series of yellow fever pestilences in Spain begins witb tbe year 
1700, wben tbe disease appeared as an epidemic at Cadiz,^ witbout, 
bowever, spreading to otber places ; tbat was also tbe case witb tbe 
subsequent epidemics in tbat town in tbe years 1730-31,^ i733-34>® 17^4/ 
and 1780.* So tbat if we except a Lisbon epidemic of yellow fever in 
1723,^ and a Malaga epidemic in 1741,^" Cadiz remains tbe only place in 
tbe peninsula tbat was visited by tbe disease during tbe eigbteentb 
century, Witb tbe commencement of tbe present century tbe sickness 

1 Bally (II), 

' Chirac, ' Traite cles fievres inalignes,' Paris, 1 742, p. 30. 

^ Palloni, Lacoste, Barzelotti, Dufour. 

4 Arejnla (II), p. 454. 

^ Fellowes, p. 23, Gonzales, p. 5, Villalba, ii, 185. 

6 Bally (I), p. 42. 

" Fellowes, p. 25, Gonzales, p. 6. 

s Ketterling. 

9 Sanchez, Bancroft (1), p. 436 (from a MS. account by Kennedy), Lyons, 
pp. 8, no. 

10 Eexano, Rubio, Villalba, ii, 203 ; see also Martinez y Montes, ' Topogr. med. 
de la Ciudad do Malaga,' Mai., 1852, p. 486. 


in Spain readied more considerable dimensions, spreading in tlie yeai's 
J 800 — 1804 from Cadiz, wliich was again first attacked, in epidemic 
form over a great part of Granada and Andalusia, northwards along 
the banks of the Guadalquiver to Cordova, thereafter deep into the 
interior, and from Andalusia to the seaboard of Murcia, Valencia, and 
Catalonia.' We meet with a second but more limited epidemic of 
yellow fever on Spanish soil in 1810; the disease broke out in the 
autumn almost simultaneously at Cadiz," Cartagena,^ and Gibraltar,"* in 
the two following years it appeared at the same places anew, and from 
them it again spread through several of the coast towns of Granada, 
Murcia, and Valencia.^ The third and last great epidemic of yellow 
fever on Spanish soil was in the years 1819 — 21 ; this time also it was 
Andalusia and Granada that svifFered most, afterwards also Murcia and 
Catalonia, in which not only Barcelona and other places on the coast 
were attacked, but also several towns in the interior, for example, Tor- 
tosa/' From Barcelona the disease was imported in 1821, as it had 
been in 1804," into Palma in Majorca.^ Since 1821 yellow fever has re- 
appeared as an epidemic four times in Spain, but always within narrow 
limits ; it was imported in 1823 into the small port of Los Passages (on 
the Bay of Biscay) by a Spanish brigantine from Havana ;^ into 
Gibraltar'** in 1828, and into Barcelona" in 1870, both times from the 
"West Indies ; and on the last occasion it was carried by the shipping 

1 See the writings of De Maria, p. 23, Bally (I), pp. 71—90, Salgado, 
Gonzalez, Arejula (I) and (IV), p. 13715—308, Armesto, Fellowes, pp. ^3, 87, 
Ferrari, Bertlie passim, Kerandrcn (II), Salamanca, Pyra, p. 20, Soucrampe ; 
further, the epidemiological reports in the ' Period, de la Sociedad med.-qulr. de 
Cadiz,' 1824, torn, iii, No. iv, Append., the ' Discorso sobre el Origin .... 
de la Enfermedad malign, cont. en la Ciudad de Cadix, 1800/ Cadiz, 1800, the 
' Manifesto sobre la Epidemia . . . de Sevilla ... en niio 1800, &c., 
Sevilla, 1800, and in the ' British Army Reports,' 1839, 10 a. 

■ Doughty, Fellowes, pp. 226, 287, Leiblin, Flores, Melado. 

' De Maria, p. 123, Vance, Proudfoot. 

* Burnett (II), Pym, p. 47, Amiel (I), Gilpin (I), Humphrey. 

5 See Fellowes, pp. 238-39, Paris-et Mazet, p. 75, Velasquez, Vance, Pym, 

p. 61. 

6 pariset et Mazet, Ferrari, Jackson (III), 9, 64, O'llalloran, Bally (II), 
Audouard (I), Rochoux, Bahi, Costa, ' Rapport .... sur I'origine de la fievre 
jaune, qui regne en 1821 a Barcelona, &c.,' trad, par Payer, Paris, 1822 ; Account 
in the 'Report general d'anat. et de physiol. pathol.,' 1826,1, i, and numerous 
notices in the ' Period, de la boc. med.-qulr. de Cadiz,' 1824, I.e. 

7 Bally (II), p. 61. 

" Id., p. 64, Almcdovar. 

8 De Arruti, Moutes, Collincau, Audouard (II), Melior, p. 301. 

10 Louis, Chervin (I), Wilson (II), Guyon (I), Amiel (II), Barry, Eraser (II). 

" ' Mcmoria historico-eientifica sobre la epidemia de febre amarilla sufrida en 
Barcelona en 1870, Sec.,' Barcelona, 1872; Larrcy ; see also Ullcrspcrger, in the 
'Bayr. urztL lutelligenzbl.,' 1870, No. 44, aud the 'Deutsche Klinik,' 1871, 
No. 13- 


traffic to Alicante, Valencia, and Palma (M:ijorca).' Finally It came in 
1878 to Madrid along with troops arriving from Cuba,- as will be after- 
wards mentioned. 

Prom 1723, when there was an epidemic at Lisbon, Portugal was 
free from yellow fever down to 1850; in that and the following year 
isolated cases wei-e observed at Oporto among custom-house officei'S and 
other persons who had been employed on board several vessels that had 
arrived with yellow fever. The fever showed itself again there in 1 856 
under the same circumstances, but to a greater extent : fi'om 21st July 
to 2nd October 1 20 persons sickened and ,'^3 of these died, and isolated 
cases occurred also at Belam and Lisbon. The epidemic at Lisbon was 
not until the following year, and it spread thence to Belam, Olivaes, and 
Almada.^ Since that time there have been occasional importations 
(1858, i860, 1864) of cases of yellow fever into Portuguese harbours, but 
they have not given rise to an epidemic outbreak.^ 

Ships witli yellow fever on board have several times 
arrived at other ports in Western Europe, as, for example, 
Brest^ in 1802, 1839, and 1856, St. Nazaire^ in 1861, Swan- 
sea^ in 1843, 1 85 1, 1864, and 1865, and Southampton^ in 
1852, 1866, and 1867. However, severe precautionary mea- 
sures, aided doubtless by the conditions of weather, have in 
most cases prevented the disease spreading from the ships 
and from the quarantine stations ; and only in a few instances, 
as at Brest in 1856, St. Nazaire in 1861, and Swansea in 
1864, has it been communicated to a number of persons, 
especially custom-house officers and ship labourers who had 
come into direct contact with the infected vessels ; at St. 
Nazaire, also to the crews of certain craft anchored in the 
neighbourhood of the originally infected ship. But it has 
never got to be generally diffused among the inhabitants of 
the ports. 

A glance at the distribution area of yellow fever as here 
sketched, shows that the whole west coast and by far the 
greater part of the interior of North America^ and the whole 

^ 'Lancet,' 1870, Oct., p. 483. 

* Account in the 'Lancet,' 1878, Nov., p. 641, and Guicbet. 

3 See ' Relatorio da epidemia de febre amarilla em Lisboa no anno 1857.' 
Lisboa : 1859, Guyon (II), Lyons. 

'* Account in tbe ' Journ. de la Sociedad das So. Med. de Lisboa,' 1864. 

■'' Keraudren (I), p. 19, Bertulus (I), Chervin (II), Beau. 

•"' Meller. 

"^ Bucbanan. 

^ Wiblin, accounts in the ' Med. Times and Gaz.,' 1866, ii, 557, 590, 672, and 
in the ' Lancet,' 1866, ii, 550, 1867, i, 119, ii, 569. 



of Africa and Europe, excepting the two regions named, have 
hitherto remained quite undisturbed by the disease. All that 
has been said about the occurrence of yellow fever in Europe 
before the discovery of America rests upon errors of dia- 
gnosis, and the same fallacy underlies the statements about 
the supposed prevalence of the disease in Asia Minor, India, 
the East Indies, and other insular or continental regions of 
Asia, which, like Australia, has never been visited hitherto by 
yellow fever. 

The geographical limits of the. yellow fever area extend, in 
the Western Hemisphere, to 34°54 south latitude (Monte 
Video), and 44°39 noi'th (Halifax), in the Eastern Hemi- 
sphere to 8°48 S. (Ascension), and 5i°37 N. (Swansea) ; but 
if we have regard only to the epidemic occurrence of the 
disease, then the parallel of 43°4 in the Western Hemisphere 
(Portsmouth, N. Hamp.), and that of 43°34 in the Eastern 
(Leghorn), form its northern limits. 

§ 8i. Chaeacteristics op an Epidemic. 

Yellow fever has occurred as a pandemic only on rare 
occasions. These are the later years of the eighteenth cen- 
tury (1796-98), the years 1819-20 (when the disease attained 
a considerable diffusion in Spain also), the year 1839, and 
then a quick succession of years, 1852 to 1853 (in which 
period the general outbreak on the South American continent 
also took place), 1855-56, 1866-68, 1873, and 1876-78. 
The increasing frequency and extent of these pandemic out- 
breaks have been obviously in proportion to the greater 
facilities of intercourse among nations, and especially to the 
development of the traffic by sea. On the other hand, as an 
epidemic prevailing to a limited extent at more or less 
numerous places, and often at merely scattered points, yellow 
fever is a permanent form of disease within the limits of 
distribution which we have already traced ; so much so 
that the annals of pestilence, from the year 1791 onwards, 
can show very few years quite free from epidemics of yellow 
fever. Even the years exempt from epidemics may bo taken 



as only apparently exempt, inasmuch as the large gaps in the 
epidemiological records from many parts of the West Indies 
and Mexico, render it impossible to give a perfectly accurate 
statement of the diffusion of the malady in time and 

An epidemic outbreak of yellow fever never happens 
suddenly ; a series of isolated cases always precede it for a 
longer or shorter pei'iod (four to eight weeks or moi'e), after 
which the epidemic will usually come rapidly to a head ; it will 
exhibit many fluctuations while it lasts, depending chiefly 
upon the influx of strangers, and will die out gradually, or, 
it may be, suddenly, under the influence of conditions of the 
weather to be afterwards mentioned. As regards their range, 
the various epidemics show great differences. Often the 
disease will remain limited to one quarter of a town, which 
forms its chief if not its exclusive seat in all yellow fever 
epidemics that occur in the place ; that is known to have 
been very decidedly the case in Charleston, Baltimore, Phila- 
delphia, New York, and Boston, and it has been partly the 
case in New Orleans, and in many of the towns in Spain that 
have been attacked more than once. Next, the disease may 
spread through several quarters of a town, and sometimes 
even over the whole town ; but, even under those circum- 
stances, it is always at a few points that it concentrates 
itself — in single houses, or blocks of houses, or streets, 
not unfrequently sparing the houses close at hand. This 
tendency of yellow fever to form particular foci of infection, 
reminds us strongly of the mode of diffusion in the case of 
cholera ; and that resemblance is manifested not less clearly 
in the fact that the disease is often confined exclusively to 
ships lying in the harbour or- in the roadstead. 

Just as in their area or range, so also in their duration, 
the epidemics of yellow fever exhibit great differences. In 
many cases, they last only a few weeks or two or three 
months ; another time, the epidemic is protracted over half 
a year or more, or it survives even several years, during 
which period numerous fluctuations of intermission and 
-exacerbation will occur, depending partly on conditions of 
the weather, partly on active movements of the population 
(influx of strangers, arrivals of troops, &c.). There are 


hardly loss marked differences in the frequency with which 
the several localities or regions are visited by the sickness, 
as we may see in the foregoing chorographic tables of the 
epidemics in the West Indies, the United States, Central 
Amei'ica, and the West Coast of Africa. 

§ 82. Influence op Eace, Nationality, and Acclimatisation, 

One of the most interesting points in the history of yellow 
fever comes up in considering the influence which circum- 
stances of race, nalionality , and acclimatisation exert upon 
the distribution of the disease. 

Neiu arrivals most exposed. — At those points of the yellow- 
fever zone where the disease bears the character of a more 
or less permanent sickness — whether endemic, or continually 
reimported, matters not — it is especially the newly-arrived 
strangers or those not yet acclimatised that are subject to 
the disease ; while the natives, Creoles, and acclimatised 
immigrants enjoy an exemption from it more or less complete. 

On this point tliere is pei-fect unanimity among observers in all 
places and at all times ; the behaviour of the disease towards the 
inhabitants of the yellow-fever zone cannot be expressed better than in 
the words of La Roche (ii, p. 25) : " Within the tropics, the population 
consists of two classes : — the first composed of the natives and accli- 
matised, who, so far as relates to the fever in question, live with 
immunity amid the sick and the dying ; the second of strangers, who 
are almost invariably attacked by the reigning disease and perish in a 
large proportion." It is this circumstance that explains the often 
observed fact, which has been already mentioned several times, that 
the disease, after subsisting for a time in isolated cases only, suddenly 
attains the proportions of an epidemic on the arrival of large bodies of 
strangers (numerous arrivals of ships, movements of troops, immigra- 
tion on a large scale), committing terrible ravages among the new 
comers, while the native or acclimatised part of the population remain' 
to the last almost exempt.' 

Special liahility of strangers from, northern latitudes. — 

^ Instances of this are given by Lebloud, p. 226, and Kerluiel for Cayenne, 
Legris for Mexico, Lciupriere, ii, 5?, 55, for Jamaica, Desportcs, i, 166, and 
Morcau (I), p. 74, for San Domingo, Davy, p. 281, for Barbadoes, Wurdemau for 
Charleston, I-'ortin, p. 312, and Drake, ii, 195, for New Orleans, and by Posey for 




The degree to wliicli this liability of strangers rises, will 
depend to a certain extent upon their nationality, ov, in 
•other words, upon the temperature of their native country ; for 
the predisposition increases in proportion as they come from 
higher latitudes, and that ratio obtains not only for the total 
amount of sickness, but also for the total mortality. '' The 
mortality of the vomito to the new-comer from the cooler 
latitudes,'^ says Townsend (II, 339), " may be said to be in 
an exact ratio to the distance from the equator of his place 
of nativity and residence/' 

Out of a large number of data supporting this fact/ I specially select 
the following. Blair states (p. 59), from experiences in Guiana from 
1837 to 1845: "The lower the winter isobar in the native country of 
those attacked, the mox'e severe was their sickness ; so that, while the 
mortality among West Indians amounted to only 6-g per cent, of the 
sick, it rose to i7"i among the Italians and French, i9'3 among the 
English, 20"3 among the Germans and Dutch, and 27'7 among Scandi- 
navians and Russians," According to the account of Barton, there 
occui-red, per thousand deaths in the New Orleans epidemic of 1853 '• 

Native Creoles 

i . 



Strangers from West Indies, Mexico, and 





j» j> 

Southern States of the Union 



5> J> 

Spain and Italy 



J» M 

Middle States of the Union 



J> )> 

New York and New England 



» J> 

Western States of the Union 


J >-• 



)} » 

British America 


J> >J 

Great Bi-itain 


» )> 



JJ » 

Scandinavia . 


J> » 

Austria and Switzerland 


>> M 

Netherlands . 


Acclimatisation. — The immunity from yelloiv fever conferred 
■hy acclimatisation, wbich is moreover not an absolute one, 
is only got by a residence of many years in a locality con- 
stantly visited by tlie disease, or, still more surely, by having 

^ See Chisholm (II), 144, Taylor, p. 205, Savaresy, p. 260, Bally (I), pp. 268, 
334, Dickinson (II), p. 13, Dickson (II), p. 257, Arejula (II), p. 325, McKiulay, 
p. 340, Arnold, p. 26, Zimpel, p. 68, Lullemant, p. 21, Wucherer (1), Jewell (I), 
Bernard, p. 2 1 . 


come safely through one attack ; a residence — even a pro- 
longed residence — in a place which is situated within the 
yellow-fever zone but is seldom or never troubled by that 
disease, diminishes the individual predisposition only a little,,, 
and, as it seems, really to no greater extent than residence in 
tropical or subtropical regions in general. 

" The chances of immunity," says Dutroulau (IV), p. 369, " appear 
to be always in direct proportion to the length of residence at the head- 
quarters of the disease ; but no acclimatisation is acquired except by 
tliose who have lived througli a previous epidemic period without 
quitting the countiy, and who have been more or less impregnated by 
the epidemic principle, and, most of all, by those who have survived an 
attack of yellow fever." To the same effect, Dowler says (I), p. 37 : " It 
is the resident city Creole, not the country creole — not the Creole who 
migrates every summer to New York, London, or Paris — that may hope 
for as good health as is possible to humanity, while two or three 
hundred others daily fall victims around him." From observations 
made in Charleston, Simons draws the conclusion : " All persons who 
have not spent a yellow-fever year there are liable to the disease, and 
it is questionable if they are wholly exempt until they have had the 
disease;" and Rufz (p. 628) informs us of the remarkable fact that, on 
the island of Martinique, which quite escaped the yellow fever from 
1826 to 1838, numerous individuals sickened (for the most part slightly) 
in the epidemic of the latter year, although they had spent six to ten 
years on the island. In every hundred deaths from yellow fever among 
the strangers in Rio Janeiro in 1876, the length of residence, according 
to the data of Rey (p. 382), had been as follows :' 

41 had resided in Rio from i day to 6 months. 
39 „ „ „ 6 months to i year. 

14 „ „ „ I year to 2 years. 

4 .. ». „ 2 years to 3 years. 

2 „ „ „ 4 years to 6 years. 

There are numerous statements to show that individuals who had 
been bom in the immediate neighbourhood of the yellow fever foci and 
lived for a long time there, have taken the disease as soon as they 
exposed themselves to the endemic influences outside their home ; such 
are the statements of Ramsay (IV) and Dickson (II), p. 257, for 
Charleston, Dowler, p. 35, for New Orleans, Kerandi'en, p. 23, for 
Martinique, Imray for Dominica, Fergusson (IV), p. 181, for Baibadoes, 
Crouillebois, p. 434, MoufSct, Heinemann (I), p. 164, (II) p. 159, and 
Watson for Mexico. 

' Further information on this subject will be found in Keraudren (I), p. 24^ 
Imray (I), p. 94, Fergusson (IV), p. 144, Doughty, p. 64, Hcincniann (I),, 
p. 164. 


These facts enable us to understand, in the next place, 
how it happens that an individual rarely sickens with yellow 
fever more than once. Some observers even consider a 
second attack to bo out of the question -^ while others go so 
far as to admit that a second severe attack occurs only in 
those who had the disease at first very mildly or, contrari- 
wise, that there may be a slight second attack when the 
first had run its course with severe symptoms ; and that, for 
the rest, a recurrence of the sickness occurs for the most part 
only under certain circumstances, which, as we shall see, 
override altogether the immunity gained by acclimatisation, 
or render it at least relatively insufficient. It follows, then, 
from the facts just mentioned, that there can be no question 
of acclimatisation at all, for regions which do not form 
permanent foci of yellow fever ; for regions where the disease 
occurs so rarely that the various outbreaks are separated 
from one another by an interval of many years, in which 
the natives and the old-established settlers sicken in large 
numbers and often mortally, and are better off than the 
strangers only in so far as the circumstances of climate 
in which they have lived, make them less predisposed to 
the illness than the latter.^ 

It appears to be still doubtful whether there is any con- 
genital immunity from yelloiv fever due to i^eculiarities of race. 
So far as relates to all the nationalities of the white race, 
the idea may bo set aside altogether ; while the relative 
immunity that the Creoles enjoy is partly referable to accli- 
matisation, partly to the circumstance that many of them 
had already got over the disease in childhood and so become 

"Those native children," says Shecut (p. io8), "that arrive at the 
age of nine years, ai e thenceforward considered as naturalised to the 
climate ; but until then, they stand equally exposed to the disease with 

1 Seaman, p. 40, Lining, Dickson (II), p. 273, Archer, p. 61, Nicholson, p. 8io, 
Barrington, p. 311, Strobel, p. 202, Dowler, p. 35, Arejula (II), p. 290. 

' There can be no doubt that the cases of repeated attacks of yellow fever are 
much rarer even than the observers admit, as it can be shown that many errors 
of diagnosis have occurred (confusion between yellow fever and severe bilious 
remittent malarial fevers) which have made a decision difficult on this as on 
many other points. 


strangers or foreigners ;" and Lota (' Arcli. de med. nav.,' 1870, Oct., 
Dec, xiv, p. 344) states : " The fevers tliat attack tlie Creole children 
during epidemics of yellow fever are more or less pronounced forms of 
that disease, and the immunity that the adult Creoles enjoy with respect 
to yellow fever, provided they have not left their country in infancy, is 
not an advantage that they owe to race or climate, but their preservation 
is due to their having had the disease before." Heinemanu (I, 164) 
takes the same view, on the ground of experiences that came under the 
notice of himself and other careful observers at Vera Cruz. The state- 
ment that children are exempt from yellow fever is shown to be entirely 
groundless by the observations made in Antigua by Chisholm (II, 
p. 281), in Guiana by Blair (IIj, at Charleston by Dickson (p. 257) and 
Simons (I), in Martinique by Rufz (p. 127), at New Orleans by Gros 
and Gerardin (p. 7), and at Cura9ao by the Dutch physicians (' Nederl. 
Tijdschr voor Geneesk.,' i860, p. 256) ; and when Faget (p. 32), Mei'cier, 
St. Yel, and others express the opinion that those illnesses in children 
which are designated as yellow fever are nothing else than severe cases 
of malarial fever, it might be retorted with better reason, as Heinemannr 
has already pointed out, that the alleged exemption of children from 
yellow fever depends on the fact that the cases of sickness occurring 
among them are always mistaken for malarial fevers. 

Immunity of the fure-hlooded negro. — For the American 
Indians (redskms)^ according to experiences in North 
America, Mexico and Brazil^, and for coolies (Hindoos), 
according to the experience of Kerhuel in Cayenne, there 
can be just as little thought of congenital immunity from 
yellow fever as in the case of the white race. On the 
other hand, such an immunity cannot well be considered 
as out of the question for the hlack or negro race. The 
same may be true also of the Mongolian stocJc ; at all 
events, Eysaguirre states (p. 12) : "The Chinese settled at 
Lima are, like the native negroes of the country, almost 
exempt from yellow fever. 


" It is a well-established fact," says Fenner (p. 56), " that there is 
something in the negro constitution which affords him protection 
against the worst effects of yellow fever, but what it is I am unable to 
say." Doughty (p. 30) expresses himself to the same effect : " In the 
natives of Africa the constitution appeared to me as secure against yellow 
fever, as a person who has had the smallpox is against its recurrence." 
Many other experienced physicians^ say that they had never seen a case 

^ Arnold, p, 34, Moultrie, p. 4, LeLloud, p. 161, Curtis, p. 244, Dickson, ' Essays,' 
i, 345, Humu (I), p. 230, Bully (I), p. 305, Eysaguirre, Gouln, Hille, p. 38, Crouil- 
lebois, p. 434, ychmidtlein, p. 56, La iloche, il, p. 65, 


of yellow fevei- in the negro, while others^ cannot but admit that the 
disease occurs much more rarely in negroes, and runs a much milder 
course, than in other races. 

That wo have here to do with a congenital and not an 
acquired immunity in the negro race may perhaps be 
inferred from the circumstance that the same immunity 
occurs in a remarkable way among negroes who have not 
been acclimatised in the yellow-fever zone, and that the 
immunity is all the more complete the more purely the racial 
-characteristics of the individual have been preserved. 

The former of these assertions is confirmed by Daniell, who mentions 
(p. 64) that in the epidemic of 1820 at Savannah, not a single case of 
sickness from yellow fever was made out among 300 negroes that had 
just been imported ; it is confirmed also by Blair, who remarks of the 
epidemic in Guiana in 1852-53 that: "Of 7890 African (black) immi- 
grants, none contracted yellow fever;"' and further by Reynaud and 
JBouffier, who agree in pointing out that among the 500 negroes from 
the Soudan and Nubia — regions free from yellow fever— who accom- 
panied the French army to Mexico, and were all the time in the fever zone 
there, not a single case of yellow fever occui-red, whereas the French 
and Mexicans were decimated by the sickness. Respecting the second 
point, Nott states : " I have seen the disease prevail five times at Mobile 
iind have attended several hundred cases among the whites, but not a 
single well-marked one in a pure-blooded negro, and not more than two 
or three in mulattoes." To the like efi"ect Fenner remarks : " The least 
mixture of the white race with the black seems to increase the liability 
of the latter to the dangers of yellow fever, and the danger is in pro- 
portion to the amount of white blood in the mixture." The same view 
is taken by Bryant (j). 299), in conformity with observations made by 
him in the epidemic of 1855 at Norfolk (.Va.) ; and Clarke (for the Gold 
Coast), Tidyman (p. 325), Nicholson (p. 856), Lewis (III) (p. 416), and 
others agree with him in saying that yellow fever is much commoner 
among mulattoes, quadroons, and other varieties than among pure 

While it is necessary to admit, according to this evidence, 
a more or less complete immunity from yellow fever, either 
■congenital or acquired, under the circumstances stated, it is, 
on the other hand, certain that this immunity may be lost 

^ Rufz (II), p. 127, Dowler, p. 38, Tidyiuau, p. 325, McKinlay, p. 340, Sar- 
roiiille, p. 36, Wuchercr (II), p. 393, Mallory. In the epidemic at Shrevcport iu 
1875, the mortality among the white population was nearly 26 per cent., while 
only 6 per cent, of the coloured population died (Jones (III), p. 151) ; the differ- 
«nce was still greater in the epidemic of 1876 at Savannah, where, according to 
WoodhuU, the respective mortalities were as 15 to 2. 


again under other circumstances, or may prove insufficient. 
As regards the first point, the most important consideration 
is a change of residence, or a considerable time spent by the 
acclimatised person outside the yellow-fever zone, and 
especially in higher and colder latitudes ; so far as concerns 
insufficiency, that depends on the severity of the epidemic. 

"Like West Indians," says La Roche (ii, 31), "tbc acclimatised 
inhabitants of our southern cities lose the protection they possessed, by 
a prolonged residence in some northern place or in a rural district in 
the same region." Hcinmann's opinion, aftxjr many years' observation 
in Vera Cruz, is : " Even foreigners may remain insusceptible to the 
disease for a considerable number of years, provided they do not leave 
the focus of disease during that period. An absence of a few months 
only is sufficient to take away this immunity. . . . That the con- 
genital safeguard against yellow fever becomes lost even in natives by 
having been away for years is a fact long recognised ; I mention the two 
following cases merely because they made an unusual sensation in the 
place. A colonel in the Imperial service, a native of Vera Cruz, found 
it necessary, after the ovei-throw of the Empire, to go to Eurupe, where 
he lived three years ; after his return he sickened so severely witli the 
vomito that his recovery was for a time doubtful. A second Vera 
Cruzan, well advanced in years, who had been at the head of the 
administration of the military hospital for thirty or forty years, died 
there in the course of last year's (1878) epidemic, having spent the few 
years preceding as a resident in the capital (City of Mexico)." By far 
the larger number of observers express themselves to the same effect.' 

Benefit of acclimatisation may he lost. — According to the 
assertions of several authorities, the immunity got by accli- 
matisation proves effective only at the place where it was 
acquired ; so that it vanishes with a change of residence, 
even when that does not involve conditions essentially worse 
than those left behind. 

Humboldt (p. 338) has already drawn attention to the fact that the 
natives of Vera Cruz may enjoy an absolute immunity from yellow 
fever at home, but when they emigrate to Havana or to one of the 
pestilential centres in the Southern States of the Union they die 
of the disease there sooner or later. Facts of the same kind are 

' Wucherer is led by his own observations, .ind on the authority of Pym, to 
give a decided opposition to this opinion; he considers an immunity once 
acquired by acclimatisation to be an absolute one. Without questioning the 
accuracy of the observations made by that author, I do not consider them 
conclusive as against the great majority of other observers, and the testimony of 
Pym is of still less account. 


given by Doughty (pp. 58, 65), Pugnet (p. 346), and others. This 
helps to explain the danger involved in removing European troops 
from one island of the West Indies to another. Let two bodies of 
troops, says Cornuel ('Annal. marit.,' 1844, ii, 739), stationed at 
different points in the Antilles, and living under the most satisfactoi-y 
conditions of health, exchange garrisons, taking every precaution, and 
cases of yellow fever will shortly break out at both places without there 
having been the slightest change in the conditions of the locality ; 
while the previous state of good health will continue vindisturbed 
among those of the troops who were left in the garrisons. As regards 
the second point (immunity lost owing to the severity of the epidemic), 
it is worthy of note that it was precisely the severe epidemics of yellow 
fever, such as that of 1S76-78 at Vera Cruz, those of 1796, 1799, 1819, 
1833, 1847, and 1853 ^^ New Orleans, those of 18 17 and 1849 ^^ 
Charleston, 1821 at Wilmington, 1805 and 1S07 in Jamaica, 1S17 at 
Trinidad, and 1852 in Martinique, in which cases of sickness and death 
were frequent (and in some of them excessive) among the Creoles and 
acclimatised strangers. 

What lias here been said as to the loss or weakening of 
acquired immunity appears to hold good in an equal degree 
for the congenital immunity of the negro race. 

"Africans who have travelled to Europe or to higher latitudes in 
America," says Jackson (p. 146), " are by no means exempt from the 
disease when they return to the West Indies;" Lempriere (ii, 29) 
adheres to this statement, adding : " This remark has been fuUy con- 
firmed by my own experience during the present year (1792-93)," and 
similar observations have been published by Veitch,i Bancroft (p. 274), 
and others. It is further noteworthy that, in the opinion of thoroughly 
reliable obsei-vers,* negroes sicken in Senegambia, on Boa Vista, the 
Benin and Biafra coasts, TeneriflPe, the parts of North America that 
are seldom visited by yellow fever, as well as in Guiana and Brazil, 
moi-e often and more severely than on the coast of Sierra Leone, in the 
West Indies, on the Gulf Coast, or at places in general where yellow 
fever is constantly prevalent. Lastly, it holds good for the negro race 
also, that their peculiar immunity proves insufficient in severe epidemics 
of yellow fever. Among numerous examples of this may be mentioned 
those furnished by the New Orleans epidemics of 1819, 1820, 1822, 1833, 
and 1853,^ t.hat of 1878 at many places in the Southern States of the 
Union,'' those of 1799, i8o7> 1824, and 1827 at Charleston,* the epidemic 

^ ' Letter to the Commissiou for Transports of Sick and Wounded Seaman, 
&c.,' London, 18 18, p. 112. 

" La Roche (II), p. 64, Dutroulau (IV), p. 369, Vergoara, McWilliam, 
Tlievenot, p. 254, Cedont, p. 344, Rush (I), p. 117, Seaman (I), p. 6. 

3 Valentin (II), p. 89, Dupuy, Thomas (I), Barton (I), p. 47, Fenner (I), p. 54. 

■• McMeurtry. 

5 Valentin, 1. c, Ramsay (VIII), Simons (I), Dickson (IV). 


at MoLile in 1819,' at Norfolk in 1855,- at Pensacola^ in 1822, in 
Guiana'' in 1837 and 1850, in Guadeloupe in 1795,* in Antigua in 1835/' 
and in Sierra Leone in 1823 7 

§ 83. A Disease op the Tiiopics and the Hot Season. 

A glauco at tlio zone of yellow fever — that region of the 
globe whore yellow fever is always prevalent, or at least 
often occurs as an epidemic, whoso range extends in the 
Western Hemisphere between 32°46 N. (Charleston) and 
22°54 S. (Rio do Janiero), and in the Eastern Hemisphere 
between i4°53 N. (Cape Verd) and 5°7 N. (Cape Coast Castle) 
— shows that the disease bears the marked impress of a tropical 
malady. It is not less a tropical malady, as the sequel will 
show, because some regions of the tropics which lie within 
the yellow-fever zone are exempt from it, or because they arc 
visited by it only exceptionally and under the same circum- 
stances as places lying outside the zone, for they enjoy a 
temperate climate in consequence of their elevation. The 
pathogenesis appears, therefore, to be essentially linked with 
trojpical climate, and that assumption is completely borne out 
by the fact that the disease is fou,nd to be dependent for its 
origin upon the season and the weather, and more particu- 
larly upon the temperature. 

Within the tropical part of the yellow-fever zone, the 
West Indies and those parts of the Mexican and West 
African coasts that are visited by the disease, yellow fever 
occurs in sporadic and endemic form at all seasons ;^ but the 
greatest prevalence of the disease falls in the period from 
April to September. 

1 Drake. 

^ Willinian, p. 165. 

3 Drake. 

^ Kerhuel, FiMser. 

'' Bishopp in Pym, p. 118. 

^ Furlong (I), p. 290. 

7 Boyle, p. 270. 

s Williams (I), p. 3, Belcher, p. 248, Savaresy, p. 32, INlillcr (III), p. 137, 
13ally[(I), p. 309, Valentin (II), p. 88, Hillary, p. 175, Bouffier, p. 529, Heiue- 
inann (1), p. 165, Boyle, p. 204. 



. 151 


• 815 

. 210 


. 769 

• 4.37 


. 720 

• ^83 


. 494 

. 1058 

November . 

. 281 

. 1078 

December . 

. 245 

According to the data of Bouffier (p. r;29)tbere were received into the 
Marine Hospital of Vera Cruz 6941 cases in the course of thirty-two 
years, the monthly admissions having been as follows : 


February . 





According to this the number of patients admitted from April to Sep- 
tember was 5123, or 73"8 per cent, of the whole. In iii epidemics of 
yellow fever in the West Indies and on the coast of Mexico, of which 
the time of prevalence is more exactly given, the beginnings and 





On the Sierra Leone coast all the epidemics except one (that of Feb- 
ruary, 1823) commenced between April and June; on the other hand, 
for reasons to be afterwards given, they commenced on the Senegambia 
coast between June and October. In the regions of South America 
situated within the northern tropic, and belonging to the yellow- 
fever zone, the epidemic prevalence of yellow fever falls chiefly in 
the months from August to December; although some epidemics (in 
Surinam 1835, Demerai-a 1851) have not begun until December, and 
others (in Berbice 1803, British Guiana 1852, Cayenne 1856) not until 
January. Lastly, in Brazil and Peru the yellow-fever season has 
hitherto been the summer and autumn (January to June). 

Of 8554 fatal cases of yellow fever at Rio de Janiero during the 
period from January, 1851, to July, 1870, there occurred in the respec- 
tive months : 

endings were as 



January . 


February . 












July . 







• ^n 











January . 






1760 I 

; J3; [ 7597 = 89 % 
996 I 



August . 
October . 



- 957 = 1 1 % 

It appears, then, that the time for epidemics of yellow 
fever is chiefly, but not by any means exclusively, the hot 
season and the rainy season in those latitudes of which wo 
have been speaking. The connexion between the disease 
and particular seasons of the year comes out still more pro- 
minently in its epidemic prevalence in countries situated in 



higher latitudes. The following table gives a conspectus of 
those yellow-fevex' epidemics of the United States and Ber- 
muda, for which the time and prevalence has been more 
exactly recorded. 

>-* » 







S oS 





r ca 












a ir 
W S 



























February . 



















f , 





2 ... 

• • • 













• •• 




1 2 























... 2 




. • • 


■ • * 


• . > 


> . ■ 


. . . 


. . . 




... 2 









... 2 





The following conclusions may be drawn from this table. 
During the first four months of the year, yellow fever has 
never been epidemic in the countries in question ; only three 
epidemics began in May, and these occurred in two towns 
(New Orleans and Charleston) which have both been visited 
by yellow fever unusually often ; the number of epidemics 
occurring in June (ig) is comparatively small; July and 
August are the mouths in which l)y far the most of the 
epidemics have begun (123 out of 180 epidemics); next to 
them comes September (31), while in October the disease 
began only four times (again in the most southern or 
Gulf Coast States), and in November and December it did 
not break out once. The close of the epidemic falls mostly 
in the months of October and November (87 times in 115 
epidemics) ; only 1 1 epidemics have lasted into December, 
and none have gone beyond that month. Summer and 
autumn therefore are the proper yellow-fever seasons of those 
regions ; the epidemics occurring before Juno or after Sep- 
tember concern the States lying farthest to the south. Thus 

' Excluding New Orleans. 


the principle formulated by Barton (p. 285), that the exten- 
sion of yellow fever from the tropics towards higher latitudes 
is regulated by the rising temperature, and that the disease 
appears later in the respective regions the farther north 
these are situated, is a law that has only a limited applica- 
tion. On the Iberian peninsula yellow fever has always 
occurred during the period from July to September ; some 
localities it has not reached in the course of its progress before 
October, and it has died out always and everywhere in 
December at the latest. 

§ 84. Relations to Heat and Cold. 

It will appear that this relation of epidemic yellow fever 
to the season is determined by the kind of weather, depend- 
ing above all upon the range of the temperature. Yellow 
fever, as a permanent disease, lasting, that is to say, the 
whole year through, and becoming sometimes epidemic even 
during the cold season, is found only in those regions where 
the mean winter temperature amounts to at least 20 — 22° C. 
(68 — 72° Fahr.), as on the Sierra Leone coast, in the West 
Indies, the northern coast belts of South America, and the 
Mexican coast ; and in these the malady does not usually attain 
to epidemic diffusion until the hot season, and seldom before 
the temperature has reached a height of 26° C.^ (79° Fahr.). 
In higher latitudes, with an isotherm of less than 20° 0. or 68° 
Fahr. (New Orleans, Mobile, Key West, Charleston), yellow 
fever occurs as an epidemic only in years when the tempera- 
ture comes up to that of tropical regions ; and then, also, 
it is principally in the hot season that it occurs. Lastly, 
in places with a still cooler climate (Central States of the 
Union, New England States, parts of Europe where the 
fever has been) the disease occurs almost without exception 
in the hot season only ; it has never grown into an epi- 
demic except when the heat has equalled the mean annual 
temperature of the tropics, and it has on no occasion become 
diffused in a temperature beloiv 20° G. (the winter tempera- 
ture of the tropics) . The same influence of a high tempera- 

^ Walter, in Bernard, p. 20, Crouillebois, p. 430, Humboldt, Hillary, p. 175, 
Valentin (II), p. 88, Belot, and various others. 

352 riEOORArniCAL and historical pathologt. 

ture upon the pathogenesis is shown also in the fact that an 
increase of the epidemic takes place not unfrequently in pro- 
portion to the rising heat, and above all in the fact that a 
considerable fall of the thermometer has always been fol- 
lowed by a considerable remission, wliilo a frost has brought 
the epidemic to an end under all circumstances whatsoever. 

" During the ten years," says Dalmas (p. 19), " that I have spent on 
the continent of America, I have always seen yellow fever following 
srreat heats and ceasing with tbo first cold." As to the extinction of 
the disease under the circumstances of a low thermometer, we find 
reliable observations from higher latitudes — for the New Orleans epi- 
demics in 1819-20-22, and -33, Opelousas 1837, Galveston, Franklin, and 
Alexandria 1839, Natchez 1817-23, and 2.r;, Vicksburg 1841, Mobile 1819 
and -54, Key West 1867, Charleston 1745-48, and -52, Memphis 1873, Nor- 
folk 1795 and -97, Baltimore 1800-8, and -19, Wilmington 1802, Phila- 
delphia 1699, 1741-47-62-97-98-99, 1802-05, and -20, New York 1791-98, 
1805, and -22, Malaga 1741, Gibraltar 1804. Barcelona 1S21 and 1870. 
The influence of this factor is manifested also within 'the tropics 
(Brazil, Peru, West Indies, Yera Cruz) in the usual remission or ces- 
sation of the epidemic on the setting in of the cold weather. 

At the same time it has to be noted that a yellow fever 
epidemic is not dependent for its continuance upon a certain 
temperature (minimum of 20-22° 0.) in the same way that it 
is dependent for its development ; an epidemic once deve- 
loped may continue with a low thermometer, and a complete 
extinction of the pestilence can only be counted on when the 
tcm'perature falls to freezing point. 

Drake (II, p. 194) concludes from his investigations : " That a heat of 
80° F. or upwards is necessary to the rise of the fever, but that having 
become prevalent it will continue under a lower temperature than that 
which is necessary to its production." Particular proof of this is fur- 
nished by the following epidemics: — Lower Louisiana 1853 [Doivler), 
Mobile 1843, Charlestown 1849 -52 and -54, Memphis and Shreveport 
1873, Norfolk 1800 and iSoi, Philadelphia 1800, New York 1795, Malaga 
1803 (the sickness continuing, as Keraudren tells us, after the neigh- 
bouring mountains were covered with snow). Gibraltar 1813 and -28, 
Lisbon 1857, Newcastle (Jamaica) 1866-67. Townsend also concludes 
from his observations made in New York from 179S to 1S22, that the 
continuance of a yellow-fever epidemic will certainly be helped by a 
high temperature, but is not absolutely dependent upon it, and that 
the sickness is as likely as not to last under a low temperature so long 
as the mercury does not touch freezing point. And Fearn (in Drake, 
II, 224) formulates from his experiences in Mobile the rule that : '• The 
cold, which merely produces white frost, will not finally check the dis- 


ease (tlie temperatnre of the ground need not fall below 40° F., for this 
effect to be produced) ; to terminate an epidemic, ice must form on the 
surface of the ground." 

There are a good many facts to warrant the inference that 
this extinction of the epidemic on the setting in of frost does 
not carry with it a complete destruction of the morbid poison. 
In those regions where the poison can be shown to have 
been imported, moro especially in Spain, it has on several 
occasions survived the winter and exerted its powers anew, 
or given rise to a fresh epidemic outbreak, when the tem- 
perature has risen again next year; as in Cadiz and Medina 
Sedonia in 1 800-1 801, Malaga 1803- 1804, Murcia 1811-1812. 
Or, it may be that the epidemic, having been checked by 
frost, has revived when the warm weather has returned later 
in the season; as in the examples of 1801 in Block Island 
{Willey, p. 103), Jumilla 181 1 [Velasquez), Barbadoes 1816- 
17 {Ralph), New Orleans 1837 {Tho7nas,-p. 60), and Memphis 
1879. The observations made on board infected ships during 
a voyage throngh various latitudes are especially instructive 
in this respect. 

Keraudren (p. 18) mentions several cases in which yellow fever had 
developed on board ships on the Gulf Coast, had persisted during the 
voyage into temperate latitudes, although the heat was much below 
19° C, had died out at last, as often happened with ships going from 
the West Indies to the coast of Newfoundland, but had broken out 
anew as soon as the ships sailed into southern latitudes after a somewhat 
short stay in northern waters. Barrington (p. 309) publishes the follow- 
ing observation : the infected ship-of-war Hornet arrived on the 29th of 
October, 1 829, at the harbour of Pensacola; the temperature there having 
fallen to 20° C. (68'^ Fahr.), only two new cases of sickness occurred, 
and when the ship left that port for New York, the disease appeared to 
have been completely extinguished. But when they were off the south 
cape of Florida, in a temperature of 25° — 28° (77° — 83° Fahr.), numerous 
fresh cases of illness from yellow fever occurred among the crew, and 
the sickness did not completely die out until the vessel reached higher 
latitudes and the thermometer had gradually fallen to fi-eezing point.' 
The effect of cold upon the extinction of the sickness was manifested 
with remarkable clearness on board the ship Narva which was employed 
in laying the telegraph cable between Cuba and Florida in 1867. On 
the 17th and i8th of September, according to Dunlop's account (p. 211), 
fresh cases of yellow fever were still occurring as the vessel lay at 
1 See also Maccoun's narrative relating to the Susquehanna in the year 185S, 
and the report of the Surgeon-General of the United States Navy in the ' Philnd. 
Med. and Sarg. Reporter,' 1879, April, p. 351. 



anchor in Key West ; when the ship left the hai-bour on the 2ist, the 
thermometer suddenly fell 15° F., and the disease was put an end to as 
if at a single blow. Not always, however, have matters gone so favor- 
ably. It has repeatedly happened that infected ships have arrived at 
North American and Eui'opean ports late in the year and in very cool 
weather with yellow fever on board ; and not only bo, but new cases of 
sickness have in several instances occurred among the ship's company 
after arrival, as, for example, at Brest in 1839 and 1856, Halifax (N. S.) 
in 1S61, and Southampton in 1866. There can be no doubt, as we have 
already indicated (p. 337), that nothing biit the lateness of the season 
and the low temperature, has prevented the infection from extending 
from the ship to the j)Oi5ulation of the port. 

§ 85. Influence op Moisture and Winds. 

The amount of 'moisture in the air and the jprecijpitations 
from the atmosphere, constitute a second factor in the pro- 
duction of yellow fever, but a less important one than the 
temperature. Some observers would make an atmosphere 
saturated with watery vapour almost up to the dew point, 
an essential condition for an epidemic of yellow fever. 
Thus, Barton, among others, states in his report on the New 
Orleans epidemic of 1853 : '^ The epidemic yellow fever has 
never occurred here at its commencement but during a high 

dew-point, the minimum being upwards of 74° 

Yellow fever has always ceased as an epidemic before 
the dew-point descended as low as 58°.''^ This asser- 
tion finds support in the evidence adduced by La Roche 
(ii, p. 130) that all countries situated outside the tropics, in 
which yellow fever is a standing disease or now and then 
epidemic, have a high degree of atmospheric moisture during 
the hot or yellow-fever season. It is further noteworthy 
that the disease occurs only to a slight extent, or not at all, in 
years with little rain, or, it may be, in an unusually late season 
when the rains have been delayed ; and that is the case not 
only in the tropics where the disease always develops on the 
setting in of the rains or directly after their cessation, but 
also in the extra-tropical regions of the yellow-fever zone. 
In the latter, the disease has been mostly prevalent in rainy 
weather,^ or has become epidemic directly after the rains ; 

' Sec Dickson (II), p. 265, Porter in tlie'Amer. Journ. of Med. Sc.,' 1854, 
Oct., p. 353, Ilosack (I), 305, Towuscud. 


dry weather, on the other hand, and especially long-continued 
drought, has proved less favorable to the epidemic diffusion 
of the disease. Finally, very abundant and continuous rains 
in tropical as well as in extra-tropical regions, have not 
unfrequently brought the epidemic to an end.' The import- 
ance of this factor for the development of an epidemic ought 
perhaps to be ascribed to the modifying influences which 
atmospheric moisture and precipitation exert upon the tem- 
perature of the air ; perhaps, also, to the dependence upon 
the same of the decomposition-processes in organic matters, 
or the growth of lower organisms connected therewith. 
But we are the less able to come to a definite opinion on 
this point, inasmuch as there are a good many observations 
that go counter to the facts above adduced ; as, for example, 
that in certain tropical regions belonging to the yellow-fever 
zone, such as the coast of Guiana^ and the Basse-Terre of 
Guadeloupe,^ dry -weather is especially favorable to tbe spread 
of the disease. 

Influence of vxinds. — The conjecture that the remission or 
even complete extinction of an epidemic after abundant and 
continuous rain has its ultimate cause in the lowering of 
temperature thereby caused, obtains some support from 
observations made on the modifying influence of currents of 
air or tlie wind, upon the behaviour of the sickness. On 
tlie Mexican coast and in the West Indies, it is the winds 
from the south — in the one case soutli-east* and in the other 
soutli-west^ — that materially help to induce the disease 
througli raising the temperature, while cold winds from the 
north and north-east have often bad a very good effect upon 
the state of health by moderating the lieat.** On the Gulf 
Coast and the Atlantic coast of North America it is likewise 
the winds from the south — south or south-east according to 

/ » 

^ See Leblond, p. 197, Valentin (II), p. 88, McArtluir iu Dickson (I), p. 4 
Arnold, p. 31, Lempriere (I), 26, Townsend (I), Gillespie (I), p. 137. 
- Fermin, pp. 3, 18, Chisholm II, 196, Hille, p. 37. 
3 Cornuel in the ' Annal. Maritim.,' II, p. 735. 
■* Humboldt, p. 765. 

5 Desportes (I), 19, Bally, p. 361, Lempriere (I), 17, Ralph, Rufz (11), p. 129, 
Savaresy, p. 189, Lefort, p. 9, Arnold, p. 26, St. Vel, ' Traite des maladies des 
regions intertropicales,' Paris, 1868, p. 76. 

6 Leblond, p. 179, Valentin (II), p. 88, Schmidtlein, p. 52, Crouillebois, p. 430. 


the geograpliical position of tlio ]ilaco — that are most to be- 
feared in this respect/ while cokl Avinds from the north have 
brought about a remission or even an extinction of the 
epidemics in those regions also." In like manner, winds 
from the south-east have fomented the sickness in Brazil (as 
at Rio de Janeiro in 1854) ; on the other hand, the setting 
in of the pamperos, — cold, tornado-like, south-west winds 
blowing from the Andes across the pampas, — was directly 
followed by its extinction in Buenos Ayres in 1858.^ It may 
be inferred that this modifying influence of the wind upon 
the morbid conditions does not reside in any peculiar qualities 
that it possesses, from the fact that even the most violent 
storms, if they last only a short time and have no permanent 
effect on the temperature, leave the state of the epidemic 
quite unaffected. In evidence of this there are observations 
from Sta. Lucia and Philadelphia in 1802, Antigua in 18 16, 
and Norfolk (Va.) in 1821. Just as little are we warranted 
by the facts before us in speaking of a '^ purifying " influence 
of thunder storms, or of any relation whatever between the 
electrical states of the atviosphere and the development, con- 
tinuance, or extinction of yellow-fever epidemics.'* How far 
the wind may be considered an active agent in carrying the 
yellow-fever poison, will be discussed afterwards. 

§ 86. Seldom leaves the Sea-Coast or the Banks op Navig- 
able Rivers. 

Not one of all the infective diseases is so decidedly local 
in character, or seems to have its existence so much bound 
up with particular circumstances of j^lace, as yellow fever ; 
and if, for the present, we can form only a very imperfect 

' Barton (I), 242, Waring, Kelly, p. 386, La rioclie ii, 1 79. On the Spanish 
coast also, as Fellowes (p. 14) mentions, the warm Levanter blowing from the 
east has had a very unfavorable eflect on the course of yellow-fever epidemics. 

'^ As at Norfolk (Va) in 1795, Boston in 1798, New Orleans in 1822 and 1837,. 
Baltimore in 1819, Natchez in 1823, and Charleston in 1849. 

3 Scrivener (I). 

* Shecut made experiments with an electrical machine upon the electrical 
tension of the air in the yellow-fever epidemic of 18:17 at Charleston. The 
conclusions drawn from them are wanting in scientific value, just as the expcri- 


■estimate of the relation between these various circumstances 
and the development and spread of the disease, yet their 
great significance for the pathogenesis cannot really be 

Among the peculiarities of distribution which show the 
dependence of yellow fever upon locality, the first to arrest 
the attention is the association of the disease, not perhaps 
exclusively, yet to a very great extent, with sea-coasts and the 
shores of great navigable rivers. 

"There is a primary fact," says Bernard (P- i8), "that ought to 
strike us, if only from its constancy, viz. that it is always in the terri- 
toiies washed by the sea, and never in the interior of a counti-y that 
we can detect the presence of this scourge ;" and if that declaration 
goes somewhat too far, yet it expresses the general conviction that has 
been forced upon all observers. This local limitation of the foci of 
sickness, which Drake (ii, iS8), Zimpel, Faget (p. 68), Hume (VII, p. 
145), and others have already called attention to, is most marked on 
the continent of North America. Among all the epidemics that have 
raged on that great region of the globe up to the year 1873, only two 
(Washington 1825, and Woodville, Miss., 1844) have occurred at places 
remote from great river-basins ; and even these were only a few miles 
tHstant (nine to twelve English). It was only in the great epidemics of 
1873 and 1878 that the disease penetrated far into the interior of 
several of the Gulf Coast States, following other routes than the 
course of the great rivers. The diffusion of the disease follows the 
same laws in the West Indies, according to Chisholm (II, p. 281, 288), 
Lind (p. 185), Moreau (I, p. 157), Bertulus, Dutroulau, and others; in 
Guiana according to Blair ; according to Baker, Dollinger, Lallemant, 
and others in Brazil (whei*e the sickness has travelled as far as the 
confluence of the Rio Negro with the Amazon, or nearly 1000 kilo- 
metres — 620 miles — into the interior, but always along the shores of 
that broad river) ; and according to Mellico, Celle (p. 83), Goupilleau, 
and others in Mexico (where it has visited inland places, but only 
exceptionally (Heinemann), following the highways of ^traffic to Cor- 
dova, a distance of 100 kilometres or 62 miles). Again, on the West 
Coast of Africa, epidemic yellow fever has always been confined to points 
on the coast ; isolated cases, imported from the coast, have indeed been 
observed in Dabon(Gold Coast) and Bakel (Senegambia),but,as Sarrou- 
ille explains (p. 36), the disease has never grown to be epidwnic at 

ments themselves were ill-judged. In like manner, no weight attaches to the 
■conclusions upon the influence of atmospheric electricity as a disease- factor 
which Belot, llufz, Bertulus, and others have drawn from the fact of an increase 
in the number of yellow-fever cases at the time of thunderstorms. Those who 
are fond of speculations of that sort will find a summary of the data relating 
to them in La lloche ii, 113 ff. 

358 GEOfiiiArniCAL and uistorical pathology. 

those places. We find a more considerable exception to the rule in tlie 
behaviour of yellow fever in the great epidemics on Spanish soil during 
the first twenty or thirty years of this centuiy ; on these occasions the 
disease not only iDcnetrated far into the interior of the country, but it 
even appeared in epidemic form at many places remote from the larger 

§ 87. Limited Altitudinal Range. 

The influence of circumstances of locality upon tlie distri- 
bution of yellow fever is shown, in the second place, by the 
fact that the disease rages almost exclusively on the x>lains, 
and docs not tend to spread at a considerable elevation, 
except in rare instances of unusually severe epidemics. 

On the continent of North America we find the limit of altitude of 
the disease to be from 100 to 200 metres, or 350 to 700 feet (Memphis, 
Holly Springs, and other places in the Mississippi valley).' In Cuba 
the hilly country in the interior has completely escaped hitherto 
(Belot), and in San Domingo, Tobago, Sta. Lucia, Dominica, and other 
of the smaller Antilles, the disease has rarely been seen at a height 
above 200 metres (700 feet). Two elevated points form an exception to 
this, the one being Camp Jacob in Guadeloupe," at a height of 550 
metres (1800 feet), and the other Newcastle in Jamaica, at a height of 
1 200 metres (4000 feet),^ the highest point to which yellow fever has ever 
yet attained ; but at each of the places the disease has been epidemic 
only once or twice altogether. On the East Coast of Mexico, again, the 
disease x'ises to a height of 800 to 900 metres (2500 to 3000 feet), as, 
for instance, at Cordova; while places above 1000 metres in height 
(3500 feet), such as Orizaba, Xalappa, and Puebla have hitherto escaped 
the sickness."* In Guiana and Venezuela the disease has always been 
confined to the coast belt ; so that, as Zimpel (p. 78) remarks, one has 
only to take a short ride up country from Caracas to leave yellow-fever 
I'egions behind. Honda, near Bogota, at an elevation of some 200 
metres (600 feet), as well as the whole of the plateau, has never been 
visited by the sickness, so far as we can tell from the data before us. 
In the interior of Brazil yellow fever must have been observed at least 
as far up as 700 metres (2300 feet), but there has never been an epi- 
demic of it at Petropolis, which stands at a height of about 1000 
metres (3500 feet), and at a distance from Rio of some five kilometres 
(three miles), notwithstanding the constant traffic with the capital 

1 Drake ii, 188, Dowler. 

- Bellarin, p. 186, Carpeiitin, p. 47, Griffon du Eellay, p. 208. 
^ Report in the ' British Army Keports,' 1867, ix, p. 226. 
'' Eouffier, p. 526, Gouin, p. 404, Schmidtleiu, p. 51, Heineinann (I), p. lOi 
(II), p. 156, Jourdauet, p. 208. 


and the frequent importation of yellow-fever cases. Furtlier, Con- 
stan^ia and San Paulo, situated at about the same height, have always 
escaped as yet.^ In Spain the fever has attained an elevation of 300 
metres (1000 feet), at the time when it was most widely prevalent in 
Andalusia; the occurrence of the disease in 1878 at Madrid (6715 metres 
or 2000 feet in height) is a fact that stands by itself in the Spanish 
annals, and it was moreover an epidemic that was limited to fifty 
cases, of which thirty were fatal. 

We cannot forget, at the outset, tliat the relative exemp- 
tion o£ lofty regions from yellow fever, depends in part upon 
the kind of climate which they owe to their elevation, i. e. 
upon their relatively low temperature. But one or two con- 
siderations will convince us that this is not the only factor, 
nor even the principal one. In the first place the disease 
stops short at many points of the West Indies where the 
climate is still in the highest degree tropical ; and that is 
true also of the town of Honda, whose temperature (28°52 C. 
or 84° Fahr.) is scarcely exceeded by any other place in 
Central America. On the other hand, there have been epi- 
demics in cool weather at very considerable altitudes, as, for 
example, at Newcastle in Jamaica. I am rather inclined to 
think that the determining circumstances here are essentially 
the same as, or allied to, those that oppose the spread of the 
disease into the interior and to points remote from such 
water-ways as are largo enough for ship traffic ; and other 
obstacles would appear to be surmounted only exceptionally 
and under circumstances unusually favorable to the diffusion 
of the disease. 

§ 88. An Urban Disease. 

Another limitation to tTie area of yellow fever as an 
epidemic may be observed in the fact of its occurring 
almost solely in places with a crowded population ; almost 
exclusively therefore in toivns, and particularly in populous 
towns. On the other hand, country districts, even those in 
the immediate neighbourhood of towns, begin to be exempted 
so soon as they present the topographical and social condi- 
tions of the open country. 

^ Eey, p. 285, Lallemaut, p. 12, McKinlay, p. 269. 


" Yellow fever," says Drake (ii, iSS), "is essentially a disease of towns 
large and small ; the country people, even within a few miles of a 
town stricken with the disease, have nothing to fear from it so long as 
they keep outside of the sphere of the epidemic. The outbreak of a 
yellow-fever epidemic in a country district is an unheard of thing, 
although it has now and then happened that a few people living in the 
country near an infected town have fallen sick of the fever." La Roche 
(II, 335) speaks to the same effect : " In the country the disease never 
occurs, however constant and intimate the intercourse may be with the 
infected place. None are there affected but those who have taken the 
disease in the latter ; and neither they nor such patients as are brought 
there from the city communicate the infection to anyone around them 
. . . On this subject the testimony of the profession is almost 
unanimous." The statements of observers from all parts of the yellow- 
fever zone bear out this last declaration most completely. The asser- 
tion may not hold good in its full extent ; for example, yellow fever 
became prevalent in the epidemic of 1800 in a few villages and farms in 
the neighbourhood of Seville and Xeres,' in that of 1795 at two places 
in the neighbourhood of Newhaven (Conn.),- in 1839 i" ^ circuit of 
some three miles around Mobile,^ in 1853 ^t several villages and farms 
in Louisiana, Mississippi, and Alabama, as well as in Texas in 1859,'' 
and in 1867 at two country estates in the neighbourhood of Pensacola.* 
But all these occurrences, as well as some of the same kind in Mexico,^ 
took place at a time of very widely spread and severe epidemics, and the 
diffusion of the disease in the country remained for the most part 
strictly limited to the localities in question. 

§ 89. Haunts the Low and Filthy Quaeteks of 


The more closely one inquires iuto tlie particulars of 

yellow fever, tlie smaller do the circles appear to be within 

which it has been prevalent at the various points of the 

yellow- fever zone ; and these boundaries in space are drawn 

still closer, or the foci of the disease contract still farther, 

when we follow the malady into its several seats. In almost all 

the places where yellow fever has been prevalent hitherto — 

equally the indigenous fever and the imported — there are 

certain points from which the epidemic has always started ; 

and those points are found to be, in seaports, the immediate 

^ Ferrari, Soiiorampe. - Monson, p. 177. 

^ Lewis (I), p. 289. * Dowler. 

5 'Philad. Med. and Surg. Reporter,' 1868, p. 228. 
^ Heincmauu (II), p. 158. 


neiglibourliood of tlie harbour and tlio wharves, ami, gene- 
rally speaking, the filthy quarters of the toivn, tlie centres of 
poverty, misery and vice, with their narrow and foul- 
smelling streets, their tenements densely crowded from 
■cellar to garret, their taverns, dancing saloons, and lodging- 
houses. It is after the epidemic has come to a head in 
those purlieus, that it begins to spread, always in tho first 
instance into the immediate neighbourhood ; but not unfre- 
quently it remains confined to them, and the other parts of 
the town some distance off, and better situated hygienically, 
may be little troubled by the sickness or not at all. 

" The places wliere tlie causes of tbe disease principally prevail," 
says Bone (p. 12), in speaking of his West Indian experiences, " are the 
vicinity of foul drains, the banks and channels of rivers which are dry 
at certain periods, the leeward openings of gullies, and crowded and 
ill-ventilated rooms and ships with foul holds;" and this statement 
is completely confirmed in the accounts of the local conditions under 
which yellow fever has been prevalent in Havana, ^ Bridgetown 
(Barbadoes),- St. John (Antigua),^' Montserrat,^ the ports of San 
Domingo^ and Martinique,'' in Gastric (Sta. Lucia),^ Port Royal and 
Kingston (Jamaica),'^ Roseau (Dominica),^ Spanish Town (Trinidad),'" 
Nassau (Bahamas),'^ and in Bermuda. •'- In Georgetown (British 
Guiana) yellow fever has hitherto been limited as an epidemic to the 
filthy streets on the Demerara river, the scenes of poverty and misery ;'^ 
and the same conditions confront us not less strikingly in almost all 
the towns of North America lying within the zone of yellow fever. 
" We find," says Bancroft (p. 227), "that in New Tork, Philadelphia, 
Baltimore, Norfolk, and Charleston this fever always begins and often 
continues exclusively in the low streets immediately adjoining to the 
harbours and whaiwes of these towns, except in the case of some 
individuals, who, after having imbibed the noxious exhalations of the 

* Barton, p. 369, Belot. 

« Williamson, 'Med. Observ. relat. to the West India Islands,' Edin., 1867, i, 
2-]. Ralph, pp. ^S' 60. 

^ Musgrave, Furlong (I), p. 290. 

^ Dyatt, ' Med.-Chir. Rev. and Journ.,' iv, p. 1003. 

^ Desportes, I, p. 51, Gilbert, pp. 18, 19, Bally (I), p. 347. 

^ Savaresy, p. 174, Leblond, p 134, Chisholm (II), 78. 

? Evans, p. 6, Levacher, p. 68. 

s Hunter (I), p. 13, Jackson (II), Miller (II), Belcher, p. 247. 

9 Imray (I), p. 78, (II), p. 319. 

1" McCabe, p. 536. 

" 'Brit. Army Reports,' 1864, vi, 255. '" Smart. 

1^ Chisliolm (II), 200, Frost, p. 209, Blair (I), p. 2>2>i account in the ' Lancet, 
J867, ii, 200, ' Brit. Army Reports,' 1868, x, 69. 


low streets in question, by residence or employment in or near them, 
happen to fall sick in other situations," For New York this state- 
ment is confirmed by Seaman (pp. 5,34), Hardie (I, pp.8, 28 ; II, pp. 2, 
16), Miller (I, p. 99), Pascalis (III, p. 2.(^1), Watts (p. 302), Townsend 
(I, p. Ill), Addoms (p. 7), and various others ; the disease in that city 
has been limited mostly to the old and new slips, Pearl Street, Front 
Street, Water Street, and the surrounding quarter. For Philadelphia 
we have the evidence of La Roche (i, 46 IF; ii, 325, 362, 369) that the 
disease has always occurred in the first instance in the quarter of the 
city situated on the Delaware, and that it has not unfrequently been 
confined to that, or has appeared at the western and richer end of the 
city only in those streets which may be classed with the harbour 
quarter as regards overcrowding, dirt, and such like. In Baltimore 
the disease in every epidemic has first appeared on Fell's Point, a low- 
lying, damp, and filthy part of the harbour quarter, and it has never 
spread from thence except along the narrow dirty streets nearest to the 
shore, and has always stopped short of the high-lying west end of the 
city. We have this on the authority of Revere (pp. 220, 237), ' Letters 
and Documents,' &c. (pp. 15, 34), Potter (p. 21), Davidge (p. 66), 
Rush (p. 24), Moores, Valentin (II, p. 71), and others. In Norfolk 
(Va.) and Portsmouth (New Hamp.) it was likewise the densely 
tenanted filthy streets near the harbovir that were always attacked, as 
we learn from Taylor (p. 150), Selden (I, p. 331), Archer (p. 61), 
Ramsay (III, p. 154), and from Bryant, who says (p. 295), after 
describing the localities : " The wonder is not that the pestilence pre- 
vailed, but that it has not annually swept the city, from the time these 
conditions began to exist," As regards Charleston, we have it from 
Shecut (p. 100), Ramsay (I, p. 26), Dickson (II, p. 265), Lewis, Hume 
(' Chariest, Med. Journ.,' 1850, p. 29), Porter (' Amer, Journ, of Med. 
Sc,,' 1854, Oct., p, 342), and from the report on the epidemic of 1858, 
which all the physicians of the place agreed to, that the districts in- 
fested by yellow fever had increased just in pi'oportion as the negligent 
public hygiene has permitted larger and larger quantities of refuse 
from the upper parts of the city to accumulate in the low-lying quarters. 
From New Orleans there come similar accounts by Chabert (p, 1 7, 23), 
Lemoine, Gerardin (p, 24), Thomas (I, p. 112; II, p. 59), Dowler (p. 
42), and others ; Barton (p. 348 ff".) calls attention to the fact that in 
the fourth district, whose sanitation was the most neglected, 7248 out 
of a population of 15,310, or nearly 50 per cent., sickened of yellow 
fever in the severe epidemic of 1858, or twice as many as in any other 
district of the city ; and Fenner gives it as his conviction (' Southern 
Journ. of Med.,' 1866, May) that the exemption from yellow fever which 
New Orleans enjoyed at the time of the occupation by the Federal 
army (during the secession of the Southern States) is not to be ascribed 
to the blockade, which was often broken, but to the " despotically " 
conducted improvements in public sanitation. Events in Natchez have 
turned out in much the same way, according to MeiTill (III, p. 217) 
Cartwright (I), and Monette (II, p. 75) ; in Memphis, according to 


Drake (ii, p. 283) and Malloy (p. 343) ; in VicksLurg, according to 
Monette (III, p. 110) and Macgruder (p. 690) ; in Mobile, according to 
Lewis (II, p. 287), Drake (ii, p. 217, 219), and others ; in St. Augustine, 
according to Strobel (p. 151) and Monette (II, p. 123) ; in Savannah, 
according to Filrth (p. 13), Waring (p. 1 1), Posey, and WoodhuU (p. 
23) ; Hill (p. 86), in Wilmington ; Warren (II, p. 136), Wheaten (p. 333), 
Holt, Cain, Channing, and others, in Boston, Providence, and other 
towns of New England. Precisely the same circumstances meet us in 
the fever-stricken ports of Brazil," Monte Video, and Buenos Ayres,- as 
well as in the epidemics that have occurred on Spanish,^ Portuguese, or 
Italian soil. In Cadiz^ the chief seat of the disease was always in the 
narrow, dai-k, filthy, and foul-smelling streets of the densely populated 
and poor Santa Maria quarter. It was the same in Gibraltar,'' and in 
Seville, where, as we are told by Berthe," the mortality in the epidemic of 
1800 was about 5 per cent, in the clean and well -ventilated streets, but 
from 33 to 50 per cent, in the low-lying, damp, and filthy streets. For 
Malaga,'' Xeres,^ Barcelona,'' and other towns we have similar accounts. 
Of the epidemic at Lisbon in 1723, we are told by Bancroft (I, p. 436), 
" The fever is vei'y contagious in the lower parts of the city, going 
generally through a family, and very few families escaping it, especially 
in the close, narrow streets ; the high parts are much freer than the 
low parts." And Lyons (p. 7) says of the epidemic there in 1875, " All 
the parts of the city largely attacked by the epidemic present in com- 
mon certain conditions of insalubrity ; defective water suj^ply, total 
absence of, or more commonly extremely deficient sewerage, total 
absence of or incompleteness of house-drains and privies, and a conse- 
quently unclean state of the streets, badly constructed dwellings, &c." 
In Leghorn the epidemic broke out in certain narrow and filthy streets, 
and it did not spread beyond the surrounding quarter, inhabited by the 
j)roletariat and neglected in its hygiene." 

§ 90. Epidemics on Board Ship. 

An interesting corollary to tlie circumstances liere spoken 
of, and a fact of especial significance for tlie etiology, is fur- 
nished by the epidemic prevalence of yelloiv fever on hoard 

1 McKinlay, pp. 260, 345, Lallemant, p. 33, Dupont, p. 32, Key, p. 281. 
^ Hiron, Scrivener (I and II), Morier, Lesson. 
3 O'Halloran, p. 1 79. 

* Fellowes, p. 33, Eerthe, p. 52, Arejula (I), p. 341, Doughty, p. 180. 
'" Bancroft, p. 473, Humphrey, p. 177, Amiel, p. 263. 
•' P. 162 ; see also Pariset et Mazet, p. 20. 
' Fellowes, pp. 158, 166, O'Halloran, p. 179. 
^ O'Halloran, p, 141. 
9 Id., 6, Rochoux, p. 86. 
1" Palloni, p. 37, Lacoste, p. 43. 


shij). These sliip epidemics, of wliicli a larg'o number have 
been observed/ show the stej^s in the origin and epidemic 
continuance of the disease as if in a tableau — on a small 
scale, indeed, but just on that account the more easy to 
survey and to analyse in the details. The epidemics on 
board ship afford proof that the spread of the disease is 
absolutely independent of influences of the soil ; they repre- 
sent foci of disease within which the malady shows a pre- 
ference, as on shore, for crowded, filthy, ill-ventilated holds, 
not unfrequcntly clinging to them exclusively, while its 
continuance on board ship is found to depend on the tempe- 
rature of the air just as on land. Sometimes it has been 
only one cabin, one deck, or one side of the ship in which 
the disease chiefly raged, afterwards spreading to other 
quarters as well, and, under certain circumstances, even over 
the whole ship." It is a noteworthy circumstance, and one 
often observed (as at Southampton in 1866 and 1867), that 
the officers and passengers of ships arriving with yellow 
fever at European ports had usually escaped altogether 
during the voyage, the cases of sickness having occurred 
among the sailors only. 

"Nowhere more clearly than in the life of merchant 
seamen,^' says Lallemant (p. 29), "do wo discover how 
essential in the last resort is filth as a cause of those attacks 
[of yellow fever] ;" and for proof he appeals to the spread- 
ing of the disease on board the filthy Finnish and Swedish 
vessels whenever these became infected. 

It often happens that yellow fever shows itself first on 
board one or more ships lying in a port or roadstead of the 
yellow-fever zone, and does not become epidemic in the port 
itself until later ; at other times it remains limited to the 
ships, without obtaining an epidemic footing on shore at all. 
In many [cases it dies out — and this is especially apt to 
happen if the disease had been present on board in isolated 

1 See Rouppe, p. 68, IJrysou (II), p. 181, Smith (VII). An excellent sum- 
mary of the observations upon yellow fever made in the Eno^lisli navy durin«- 
recent years is given by Fricdcl ('Die Kranklioitcn in der Marine, nach den 
" Reports of the Health of the Royal Navy," ' Rerliu, 1866, pp. 102, 190, 208, 
218, 246). 

- See Fergusson (IV), p. 142, Wilson (I), p. 158, Pellarin, p. 1S8, Ricque, 


cases only — as soon as the vessel leaves the port and gains 
the open sea ;^ while, in other cases, it continues as long as 
the ship's course is in low latitudes. Under theso circum- 
stances, it has often been observed that the disease has 
undergone a remission or even died out altogether when tho 
ship has reached higher latitudes, and that it has been 
lighted up afresh as soon as she has come again into warmer 
regions. Under such conditions yellow fever has been 
enabled to continue on board ship for weeks and even 
months.^ Wo shall afterwards see how prominent a part in 
the epidemic history of the disease such infected ships i:)lay. 

§91. Geological Chakacteks of the Soil of no Account. 

The last important point in the inquiry before us is the 
question as to the influence that conditions of soil appear to 
have upon the production and diffusion of yellow fever. 
Whether the Idnd of rode has any significance in this respect 
cannot be settled offhand, in the absence of all exact 
inquiries directed to the point ; this much, however, is 
certain, that the disease has become epidemic on the most 
various geological formations. 

Wilson (* Memoirs/ pp. 89, 127) has pointed ovit that yellow fever, in 
its epidemic occurrence in tlie West Indies, appears to liave been 
mostly associated with a clialk soil (belonging to the secondary forma- 
tion), and be instances the prevalence of the disease in Jamaica, 
Trinidad, Martinique, Guadeloupe, San Domingo, and Barbadoes. 
But the disease bas been observed not less frequently upon volcanic 
soil in St. Kitts, Guadeloupe, Dominica, Sta. Lucia, and Grenada. It 
prevails over a wide extent of .tbe alluvial soil of Mexico, Brazil, Peru, 
and Guiana, and not less upon the diluvium and the tertiary forma- 
tions^ wbicb extend from Texas along the southern and eastei-n coasts of 

1 Trotter (I), p. 358, Gillespie (I), p. 12, Morgan (I), p. 9. 

2 Gillespie (I), i)p. 48, 53, Auderson (I), p. 21, Doughty, p. 16, Caillot, 
p. 199, Keraudren (I), p. 18, Moreau (I), p. 122, Lallemant, p. 115, Vaiidcr- 
poel, 'New York Med. Record,' 1872, Dec., p. 82. 

3 Dowler points out that in the great epidemic of 1853 the disease was exten- 
sively prevalent on the high plateau with a diluvial soil which extends, under 
the name of the Bluffs, from Lake Pontchartrin, a long way up between the 
Mississippi and Pearl rivers, and which had been previously thought to be exempt 
from yellow fever. In the same epidemic the disease occurred also upon the 


tlac United States as far as New Jersey. When tlie disease broke out 
in Spain, it was repeatedly epidemic upon clialk soil (in the liilly 
country of Cadiz), and upon Jurassic limestone (Yalcncia, Gibraltar, 
&c.), and even the oldest formations (granite and transition rocks) 
have not been exempt, in the outbreaks of yellow fever on the coast of 
Sierra Leone and of New England. 

§ 92, Malarious Conditions of Soil are Irrelevant for 

Yellow Fever. 

It lias always been a subject of special interest to find 
out how far, if in any degree, yellow fever depends for its 
development and diffusion upon physical characters of the 
soil, upon the porosity, and saturation, and the amount of 
organic matters contained therein ; how far the disease, in this 
respect, is allied to the malarial diseases. The inquiries 
directed to this point were for a long time vitiated by an 
error to which we have several times adverted in the course 
of these investigations ; many observers have confounded 
yellow fever with malarial fever from the pathological point 
of view, and that is the chief reason why yellow fever has 
been pronounced to be a disease of the soil or a swami') disease, 
and has been ranged alongside the malarial fevers in its 
causation. It is only the experiences of the most recent 
times that have introduced a more rational conception of the 
problem and have effected a disentanglement that was much 
wanted ; so that the number of those who at the present 
day adhere to the malarial theory of yellow fever — its ad- 
herents were chiefly found among American and English 
physicians — appears to bo reduced to a very small figure, 
and the doctrine that yellow fever is dependent to some extent 
for its origin upon influences of the soil has been brought 
within proper limits. 

Among the Lesser Antilles it is precisely those which, by reason of 
the conditions of their soil and especially of its swampy character, 
have been the principal scats of endemic malaria, that have been the 
least visited by yellow fever; whei'cas other islands, whose dry and 
rocky soil has prevented the endemic prevalence of malaria, have been 

tcrtiiirj' soils of Louisiana and Mississippi States at an elevation of 100 metres 
(330 feet) and upwards. 


by far the most frequent scenes of yellow-fever epidemics. Fergiisson, 
one of tbe best wi-iters upon yellow fever, observes :' — " In the West 
Indies there are regions with as dry a soil and as free from swamp as 
are to be found anywhere on the globe ; let us seek out the most 
favourable spots among them and send European troops there, and 
provided the place be on the coast, they will be decimated by yellow 
fever as surely as if we had sent them to Demerara or to any other 
of the most swampy places in the world." The same opinion has been 
expressed by Imray," Anderson,^ McLean (p. 25), Wilson (pp. 99, 129), 
and others with refei'enco to Barbadoes (to which Fergusson had 
specially referred), St. Kitts, St. Vincent, Montserrat, and certain dry 
yellow-fever localities of San Domingo. From another quarter, 
Stewart (p. 186) in his report upon the yellow-fever epidemic of 1793- 
95 in Grenada, declares that the disease spared entirely just those 
places where malarial fevers pi-evail most. McCabe (p. 535) obsei'ves 
that yellow fever is comparatively rare on Trinidad,* one of the most 
marshy islands of the West Indies, and has been observed to be always 
confined to a few points, especially Port of Spain. Morean^ points out 
that the yellow-fever epidemics which were known to have occurred in 
Martinique up to 1820 had affected the two ports of St. Pierre and 
Fort Royal almost exclusively, while many places situated in the 
midst of swamps, some of them in the interior and some of them on the 
coast (for example,'Port Marie in the south of the island), had escaped, 
the same being true of all subsequent epidemics. The disease has 
never occurred in the notorious swamp districts of the interior of 
Guiana f' and it would not be fair to attribute its endemic prevalence in 
Vera Cruz to marshy influences, for Jourdanet (p. 184), Ci'ouillebois 
(p. 430), and others are unanimous in saying that the town suffers 
from malaria much less than the Tejeria, which is surrounded by 
marshes and is yet very rarely visited by yellow fever. " The 
Mexican coast," says Heinemann (II, p. 157), speaking generally, 
" affords numerous proofs that yellow fever is absolutely independent 
of so-called malarial fevers." The yellow fever of Charleston has 
never extended to the swampy districts of South Carolina, nor has it 
spread from Mobile over the damp flats of Alabama, or from Savannah 
over the rice-fields of Georgia ; and, whereas malarial fevers have 
decreased remarkably in Charleston within recent years in conse- 
quence of improved drainage, yellow fever has continued up to 
1 87 1 as frequent and as malignant as before." Bakel and Dabon, 
two notoriously malarious localities, the one in Senegambia and 

^ ' Edin. Med. and Surg. Journ.,' 1843, July, p. 186. 

2 lb., 184s, Oct., p. 332. 

3 'Facts,' &c., p. 16. 

•^ Like British Guiana and Brazil, Trinidad has suffered much from yellow 
fever since that was written (18 19). 

5 'Memoire,' &c., p. 157. 

6 Bertulus (II), Blair. 

7 Gaillard, 'Transact, of the Amer. Med. Assoc.,' ii, 577. 

368 OEonRAririCAL and tiistortcal pathology. 

the other on the Gold Coast, have never had an epidemic of yellow 
fever, although there have been often cases of the fever there, 
imported alou<» the coast from Gorec and Grand Bassam respectively. 
In the epidemics of yellow fever which spread to a great extent over 
Spanish soil, it was precisely the elevated and dry-lying places that 
suffered from the sickness, while damp or marshy districts in their 
neighbourhood escaped; numerous examples of this might be adduced 
from Gibraltar, Medina Sidonia, Murcia, Xercs, and other places.' 

A decisive argument in the question before us is afforded, 
on tlie one liand by the fact that yellow fever, in contrast to 
malaria, is met with properly in totvns only, and quite 
exceptionally in country districts ; and, on the other hand, 
there is the best argument of all in the epidemic occurrence 
of yelloio fever on hoard ship. Chabert (p. 21) and Wilson 
(p. 8g) arc therefore right in stating that, if yellow fever 
occur at all in a marshy region, it is not the swampy soil 
but something else pertaining thereto that gives occasion to 
the development of the disease. At the same time, it should 
not be supposed that the soil, or the processes of decom- 
position occurring in it or upon it, are altogether without 
influence upon the production of yellow fever. Thus, it has 
been often observed that the brcaking-up or turning over of 
the soil, the excavation of canals, the laying out of streets, 
embankments, and other such earthworks, appear to have 
had something to do not only with the outbreak of the 
disease, but also with its diffusion. 

"For a century or more," says Jourdanet (p. 180), "the Spaniards 
who followed in the footsteps of the first adventurers to the New 
World do not appear to have died as the victims of the vomito negro. 
It was only after they had increased in well-being by clearing and 
cultivating the land, and had therein provided new guarantees for the 
maintenance of their health, that the yellow fever appeared among 
them, and spread widely over the newly drained localities." To the 
same effect is the opinion of Thomas (' Essai,' p. 72), on the outbreak 
and spread of the disease in Cuba and San Domingo. The first epidemic 
of yellow fever at New Orleans occurred, as Thomas (ib., p. 70) remarks, 
at the time when the channel of the Carondelet Canal was being exca- 
vated ; Barton points out that many of the subsequent severe epidemics 
of yellow fever there (especially those of 1S11-17-19-22-32-37-53) were 
coincident with canal undertakings, and that the same fact was 
observed at Francisville and other places in Louisiana in 1827-29-39. 

' See Pym, pp. 31, 134, I?ally (I), p. 355, Ferrari, p. 370, Parisct ct Mazet, 
p. 75, Bally, Fran9ois et Pariset, p. 460. 


Accounts of the same kind come from Mobile, Natchez,' Cliarlcston,^ 
New York,^ Trinidad,^ Martinitpe,'' Grand Bassam, and other pkices, 
several of the observers pointing ont that the number of cases of sick- 
ness and of death from yellow fever reached its highest point in the 
neighbourhood of the places where the earthworks were being made, 
and among the labourers who were employed upon "them. 

§ 93. Nature and Origin op the Morbid Poison. 

For yellow fever, as for all infective diseases, a specific 
and material morbid poison must be assumed. We must 
abandon, as misdirected, all attempts to discover the 
genesis of the disease in the action of atmospheric forces — in 
high temperature, either by itself or in association with 
extreme degrees of atmospheric moisture, great electrical 
tension of the atmosphere, and the like. But while there 
■can be little doubt as to the material and specific character of 
the morbid poison, the precision hitherto reached in the 
views about the nature of the poison has been just as slight 
in this, as in nearly all the other infective diseases. 

It is highly probable, for several reasons mentioned above, 
that the development or multiplication of the yellow-fever 
poison stands in a certain causal connexion with processes 
of decomposition in organic matters ; and thus we are con- 
fronted here with the same question as in malaria and all other 
acute infective diseases : whether namely, the disease-produc- 
ing factor is to be sought for among those decomposition-pro- 
ducts themselves, or in whatever sets the decomposition 
agoing, or in other organic (or organised) forms standing in 
a certain relation to the processes of putrefaction. 

Hypotheses as to the nature of the yellow -fever foison, 
leaning sometimes to one side, sometimes to the other, have 
exhausted the ingenuity of the profession without advancing 
our knowledge by a single step. 

1 Merrill, 'Philad. Jourii. of Med. and Phys. Sc.,' 1824, ix, p. 240, and 'Mem- 
phis Med. Recorder,' i, 87 ; Barton, p. 317. 

2 Simons, 'Chariest. Med. Journ.,' 1853, viii, p. 363; Wragg, in La Roche, ii, 
p. 405.. 

3 Bayley, ' Account,' &c., p. 59. 

4 McCabe, p. 535. 

^ Ballot, 'Arch, de med. nav.,' 1870, Jan., p. 61. 



One of tlie boldest liypotheses as to the septic nature of the 
poison is that which has been elaborated by Audouard.' In his opinion 
the poison of yellow fever has been engendered in the crowded, filthy, 
nnventilated holds of slave-ships. They were the first means by which 
the sickness was ever brought to the West Indies and the mainland of 
America. Although the poison had not proved dangerous to the 
negroes themselves, it clung to the ships, and had been repeatedly taken 
to Europe on the voyage back with a cargo of merchandise. This view 
of the impurtation of the disease by ships conveying negroes is also 
applied by him to explain the more recent general outbreak of yellow 
fever in Brazil.- Some observers have hazarded the conjecture that 
the yellow-fever poison is generated out of the putrefaction of certain 
marine animals, especially the madrepores, which accumulate in large 
quantities on the shores of the West Indies and of the Gulf of Mexico.^ 
The view that the origin and reproduction of the i^oison is specially 
related to timber has been particulai-ly well received. Fergusson'' was 
the first to apply it to explain the frequent occurrence of the disease on 
board ships, and their tenacity of the poison. After him Rochoux, 
and more especially Wilson,* pointed out that it was just the ships 
with cargoes of timber that chiefly became foci of yellow fever ; and 
Wilson at the same time directed attention to the fact that, on shore 
also, the disease occurred with especial frequency at places where there 
was much decaying wood, as on wharves, docks caissoned with wood, 
and ships' moorings. This view has found supporters in Bryson,^ 
Bush, and others. In other quarters special weight has been laid on 
certain cargoes, particularly sugar and coal / while others again have 
attributed the direct cause of epidemics on board ship to the decompo- 
sition of the organic matters contained in the bilge-water.^ 

In the most recent times, investigators have inclined more to the 
theory of a parasitic origin of the disease," although no one has yet 
succeeded in adducing a single positive fact upon which to base this 
theory. It is clear that the assumption of a parasitic origin for yellow 

' 'Revue mud.,' 1824, Nov., iv, 227. 

- lb., 1850, July, ii, 67. 

' Mahcr, ' Relat. mod. de deux opidemies de fievre jaune a bord de la fregate 
d'llerminie, 1817-38,' &c., Paris, 1839, P- '31; Certulus (II); Dupont, p. 57, 
and others. 

4 ♦ Med.-Cliir. Transact.,' I. c. 

5 'Memoirs,' &c., p. 139 iV. 
f- ' lleport,' &c., p. 229. 

7 The disease has, in fact, occurred remarkahly often in sugar ships and coal 
ships, which are distinguished in general from other merchant ships by want 
of cleanliness. See Townsend, in the 'New England Jouru. of Med.,' xii, p. 381 j 
Buckley, 'New York Journ. of Med.,' 1856, Sept.; Melier, pp. 256, 301. 

« Archer, p. 61, Barrington, Macconn, p. 325, Gibhs, p. 344, Ricque, Jewell (I), 
Hommtl, p. 7, Schmidtlcin, p. 51. 

'■> Pellarin, Melier, Schmidt, Gaillard, Gibbs, Macdonald in the 'Statist Rep. ou 
the Health of the Brit. Roy. Navy, i860,' p. 77, Nott, Sternberg, and others. 


fever is incompatible with the spontaneous origin of the disease ; 
and it is in this sense that Macdonald, one of the most decided 
partisans of the parasitic theory, expresses himself when he says : 
" There is no more proof of the spontaneous development of a monad 
than of an elephant ; the doctrine of the spontaneous origin of the 
yellow-fever organism or cause, if this premise be sound, can have no 
foundation to satisfy the rational mind." 

§ 94, The Question op Communicability. 

But this want of acquaintance with the nature of the 
yellow-fever poison does not prevent us from obtaining a 
tolerably clear insight into the way in v)hich the disease 
spreads ; including the question whether the native habitat 
of yellow fever extends as far as the area of its distribu- 
tion, or whether it is endemic at only a few points on 
the globe, occurring elsewhere merely in consequence of 
importation of the morbid poison ; and, in the latter case, we 
have to inquire by what media and in what ways that 
importati(m takes place. 

The question so keenly discussed a good many years ago 
as to the comraunicahility of yellow fever has been definitely 
answered in the affirmative by the most recent events in 
Brazil and Peru, at Lisbon, Barcelona, and elsewhere ; and 
if there are still some differences of opinion among the 
observers, it is not now a question whether communication 
actually takes only, but only of how it takes place. And 
those differences depend not so much upon conflicting facts, 
but rather upon the significance ascribed to them ; and they 
arise above all from the futile endeavours to interpret the 
facts according to our conventional and obscure notions of 
^'contagium" and ''miasma.'^ If we are to understand by 
contagion that kind of spreading of a disease in which we are 
concerned with infection of an individual by direct convey- 
ance of a morbid poison reproduced in a specifically diseased 
organism and eliminated therefrom, then, for yellow fever, 
that mode of disease-conveyance has to be at once dismissed. 
It is at variance with the character of a '^contagious" disease 
that it should prevail, as in the case of yellow fever, almost 
exclusively among the population of the coast or river shore 


and indeed anion<^ urban populations, that it sliould occur only 
exceptionally under other circumstances of locality, and that 
it should almost entirely spare not only the country popula- 
tion who are engaged in open traffic with the infected place, 
but the interior in general, and that too in spite of the intro- 
duction of numerous cases of the disease, especially among 
the large numbers of fugitives from the infected towns who 
resort to the country.^ In very many cases, yellow-fever 
patients have been landed from ships without the disease 
being communicated round about, whether in the hospitals 
or in the private dwellings into which they have been 
admitted. Even the most intimate kinds of contact, such as 
the healthy and the sick sleeping in one bed, the attendance 
of physicians and nurses upon the sick,^ the use of the 
uncleansed linen, clothes, or bods of yellow fever patients,^ 
post-mortem examinations of their bodies,^ and the like, have 
in no wise contributed to the spread of the disease. 
Particular emphasis has been laid in some quarters upon the 
fact that specially designed experiments to induce infection 
by the inunction or inoculation into the skin of the vomit of 
yellow-fever patients, and by the wearing of the linen and 
clothes used by the sick and saturated with their perspira- 
tion, have always yielded a negative result.^ 

The experiences of the frightful yellow-fever epidemic of 
1878 in North America have proved highly instructive in 
this respect. There is but one opinion as to the non-con- 
tagiousness (in the strict sense) of yellow fever, held by those 

^ See the accounts of Lining and Eamsay (VI) from Charleston; of Smith 
(IV), p. 109, Baylcy (II), p. 126, and Millor from New York; of Hush (I), p. 132, 
and Doveze, p. 220, from Philadelphia; of Bowen (II), p. 338, from New Provi- 
dence; of Cliabert, pp. 21, 97, Gros et Girardiu, p. 7, and Thomas (I), p. 144, 
from New Orleans; of Monette (II), p. 75, from Natchez; of Goupilleau from 
Tampico; of Eaker, Lallemant, and others from Brazil; of Mautegazza from 
Buenos Ayres; of Boyle, p. 291, from Sierre Leone; and of Guyon (II), j-i. 44T, 
from Lisbon. 

^ See Clark (I), p. 22, LeLlond, p. 226, Potter, p. 21, Vaughan (I), p. 371, 
Dunlop, Porter (III), O'llalloran, p. 102, Lacoste, Fiirth, p. 17, Scrivener (I), 
Sternberg, and others. 

■'' Valentin, p. 122, Devoze, p. 221, Birnie, p. 336, Barringloii, p. 310. 

■• Deveze, p. 239, Gillespie, ' Observ.,' &c., p. C9, Ivochoux, ' Kecherch.,' &c., 
p. 315, Doughty, p. 49. 

*> llochoux, 1. c, Deveze, p. 13, Dupuy, Guyoii after a statement by Donzelot. 


wlio liavo published accounts of that cpiJomic (Stillc, Lynch, 

Thomas (VI), Whittaker, Woodworth, Bayley (IV), and 

others) ; the scientific commission appointed to inquire into 

it have reported to the same effect ;^ and that may be said 

also to be the conclusion recently arrived at by Lawson after 

a very thorough inquiry into the spread of the disease on the 

Sierra Leone Coast and in the West Indies, both on land 

and on board ship. Lawson's opinion is summed up in 

these words : — " Healthy persons going into a locality where 

the cause [of the disease] was known to be in a state of 

activity were very liable to be attacked, but if they or others 

infected in such a locality returned to a healthy one, they 

went through the fever there Avithout communicating it ; 

there was no evidence to show that persons labouring under 

the yellow fever, or the bodies of those who had died of it, 

gave off a poison capable of exciting the disease." This 

passage may be taken to express the most recent conviction 

arrived at by the whole of the medical world acquainted with 

the circumstances in question. 

But if the question concerning the contagious character of 
yellow fever is decisively answered in the negative, just as 
certainly do all the facts point conclusively to coiyimunica- 
hility of some hind. Setting aside certain of the "West India 
Islands, a part of the Mexican Gulf Coast, and the coast of 
Sierra Leone, we find that at all other places where yellow 
fever has ever been prevalent, the outbreak of the epidemic, 
or even the occurrence of isolated cases of the disease, has 
ahvays followed shortly after the arrival of ships from ports 
where the disease was known to be epidemically prevalent at 
the time of their sailing,^ or which were notorious as endemic 
foci of yellow fever.^ In most cases, the ships have had yellow 

' 'New York Med. Record,' 1878, Nov., p. 434. 

'■' It may be mentioned here that the carelessness of sanitary authorities at 
ports of arrival has played a very disastrous part in the history of yellow fever, 
especially in the last century. The mischief hcin^ done, those officials often 
attempted to envelop the facts in obscurity, and thereby to cover themselves. 
They would bring forward evidence to show that cases of yellow fever had 
occurred before the arrival of the infected ships, and so forth. 

3 "In the West Indies one should never trust," says Friedel (p. 224), "the 
rumour that there is no yellow fever. A ship of war is always a mine of wealth 
to the inhabitants of these colonial ports, and they are careful to keep silent 
about the sporadic cases of yellow fever that occur from time to time, so as not 


fever on board on tlicir arrival, or liave had it on board 
dnring the passage ; but there are also well authenticated 
cases in which such an importation of the disease has taken 
place from ships which had sailed from infected ports, but 
on board of which no yellow-fever sickness had occurred, 
either among the crew or among the passengers.^ 

The causal connexion between infected ships and the out- 
break of the disease at the ports where they have arrived 
comes out still more decidedly in those frequently observed 
instances where the first case of illness, sometimes even a 
whole series of cases, has originated on board the ship itself 
among custom-house and quarantine officers, pilots, ship 
labourers, and others, or where the starting-point of the 
infection has arisen through indirect intercourse with the 
infected ship, by means of goods, ballast, stores, clothing 
of the crew, and the like unladed from it.^ 

At the present day, we cannot longer doubt that the 

instances of yellow fever in European ports, the outbreaks of 

it on the coast of Senegambia,^ and in the islands off the 

West African coast, the epidemics of it on the continent of 

to interrupt the shipping ti-affic and theu* own huaincss." What is here said of 
ships of war applies equally to merchant ships, as we may learn from numerous 
accounts ; in fact, cases of the latter kind arc met with more frequently, inasmuch 
as there is often a want of a due degree of caution on the part of the captain. 

^ Cases of that sort have been published by Hohenberg from New York, and 
by Jewell (I) from Philadelphia. One of the most interesting cases occurred in 
the recent outbreak of the disease at Madrid in 1878. Among a force of 17,000 
to 18,000 troops returning from Cuba, not a single case of yellow-fever sickness 
occurred either on the voyage or subsequently. The troops disembarked at San- 
tander, and about one half of them were sent by rail to Madrid along with their 
unopened bage:agc. The baggage was not unpacked and cli^ansed until it reached 
the capital, whereupon it gave rise to an outbreak of the disease. The soldiers 
themselves, who were, to be sure, acclimatised, remained exempt from it. " The 
yellow fever at Madrid," says Guichct, "was due to the importation of morbid 
germs among the clothes and baggage of men in good health returning from 
Cuba;" and the writer in the 'Lancet' (1878, Nov., p. 641) expresses the same 

* The first cases in the New Haven epidemic of 1794 occui'red in individuals 
who had been employed on board a vessel from Martinique in removing the 
clothes of several persons who had died of yellow fever on the voyage (Monsou, 
p. 174; 'Additional Facts,' &c., 2>. 50). 

3 Fergusson had stated long ago ('Lond. Gaz.,' 18.39, P- '*^.^9) that yellow fever 
occurred in Senegambia only after imiiortation frona Sierra Leone; and that 
opinion has been subsequently confirmed by Theveuot (p. 254), Cedont, and all 
later observers. 


South America, as well as tlie cases that occurred previous 
to 1820 in some New England ports, have always been asso- 
ciated with the arrival of infected ships ; and it is now 
equally l)cyond doubt that in New York, Philadelphia,^ 
Baltimore, Norfolk, and other seaports of the Central States 
of the Union, yellow fever has never occurred without an 
infected ship having arrived just before. This fact has been 
longest in getting accepted for the United States ports on 
the southern part of the Atlantic coast and on the Gulf 
coast ; but for these also, particularly Charleston, Savannah, 
the Florida ports, and Mobile, the conviction has almost every- 
where gained ground that every outbreak of yellow fever in 
them (apart from exacerbations of slumbering epidemics 
such as have occurred also in Spain and South America) 
may be brought into connexion with the arrival of vessels 
from suspected ports. 

"It is difficult," says Dickson ('Chariest. Journ.,' 1856, p, 749), "to 
argue with a man who can now doubt the communicability of tliis 
pestilence, its transportation, or the transportation of its cause, from 
place to place ; . . . . Whether it occurs in New York or Boston, 
Philadelphia or Baltimore, Norfolk or Chaiieston, Savannah or Mobile, 
it is always coincident with or suljsequent to some foul arrival from the 
West Indies or New Orleans, perpetual sources, as I suppose will be 
admitted, of the pestilence." 

In the most recent times, and especially since the expe- 
riences of 1867-78, scarcely a doubt exists that even in New 
Orleans the disease is not endemic but always imported, and 
that yellow fever, therefore, must be regarded as a disease 
everywhere exotic to United States soil." 

The history of yellow-fcver e^ndcmics on hoard ships 
themselves furnishes an additional and important contribu- 
tion to the doctrine that the disease spreads by way of 
communication. Ships have got yellow fever only when 
they have been in direct or indirect intercourse with other 

^ The attempt made by La Roche to show that the appearance of yellow fever 
in Philadelphia had not depended upon the imijortation of the disease by ships 
has quite miscarried, inasmuch as the author has confounded yellow fever with 
bilious remittent malarial fever. 

" Woodward, ' Iloport on Epidemic Cholera and Yellow Fever in the Army of 
the United States during the year 1867,' Washington, 1868; Stille, Woodworth, 
and various others. 

376 GEOGriArnicAL and historical tathology. 

ships already infected, or with an infected slioro ; and there is^ 
not in the whole literature of yellow fever a single accredited 
instance of tho occurrence of tlie disease on board a ship 
voyaging to, or moored within tho yellow-fever zone, in which 
that condition has not been fulfilled. 

So long, says Frasei- (' Lond. Med. Gaz.,' 1838, xxi, p. 642), as a ship 
lying in a yellow-fever port keeps clear of all communication with the 
sliore, no case of yellow fever will show itself on board ; but the strict 
rules adopted by captains in these cases seldom continue to be observed 
longer than the first week or two, after which time someone or other of 
the crew steals ashore to visit a friend or to make a purchase, and, with 
that, the ship's protection from the sickness is gone. Friedel also points 
out how often, in ships of war, the disease is bi'ought on board by those 
sailors who row the officers ashore, and have often to wait for hours to 
row them back. A most complicated case of the transmission of yellow 
fever from one ship to three others, and to the shore, is related by Bryson 
(■ Epidemiol. Trans.,' i, 187). A vessel having been infected on the coast 
of Mexico or of San Domingo, brought the disease first to Port Royal, 
and came into communication there with the crew of a second ship, on 
board which cases of sickness occurred shortly after; from the latter a 
third was infected through surplus hands being transferred, while fiuallj' 
the disease was conveyed from the first ship to another (the fourth), and 
at length to the hospital of Port Royal. 

We find a complete analogy for these ship epidemics in 
the behaviour of the disease on land within the infected 
towns. An analysis of any yellow-fever epidemic shows 
certain groups of cases so arranged as to constitute separate 
foci of disease, sometimes in single houses, sometimes in blocks 
of houses, or, again, in streets or groups of streets ; so that 
each new case of disease, as it occurs, may bo traced to 
infection of the individual within any one such focus. That 
case may in its turn become the centre of a new focus ; but 
outside those centres of disease there is complete immunity. 

The importance of these foci of infection for the diffusion of the 
disease had been already rightly appreciated by many observers in the 
latter half of the last century — by Monson (p. 177), McKnight (p. 293), 
Addoms, Steward (p. 123), Chisholm (II, pp. 96, 107), Warren (p. 136), 
and others. Observations to the same effect were published for the 
Spanish epidemics by Pellowes (p. 287), Bally (p. 82), Pym (pp. 20, 47), 
and almost all the other chroniclers. Guy on (II, p. 441) remarks con- 
cerning the Lisbon epidemic of 1857: "Once in a house, the scourge 
will always carry off a larger or smaller number of victims from it ; 
further, whether there are still side persons in it, or whether there are no- 


longer any, that hoiisc unll become a centre to reproduce the disease in the 
stranrjcrs who enter it ; and what is true of a whole house applies also to 
a part of it." Many ohservers have reported to the same effect from 
North and South America, the West Indies, and Mexico; and even 
Blair, one of the keenest opponents of the doctrine of the com- 
municahility of yellow fever, cannot but admit that the disease is 
always confined at first to single foci, from which it spreads and forms 
new foci of infection, and he adds : " Outside these boundaries of epidemic 
injluence there was safety." 

§ 95. Goes no farthek than Maritime Commerce goes. 

The reason for tlie limitation in space of a disease 
intrinsically communicable — for that is very markedly the 
character of yellow fever — must bo sought for, assuming 
that there is free traffic between infected and healthy places, 
either in certain local conditions, whether of the attacked or 
the exempted locality, or in the media by which the com- 
munication of the disease is effected, or finally in a pecu- 
liarity of the morbid poison itself. As regards the last 
point we are not able to say anything at all ; and even with 
reference to the first, an impartial and thoroughly objective 
review of the facts affords nothing on which an explanation 
of the circumstances in question might be based. Neither 
in conditions of temperature, of soil, of social life, of hygiene, 
or of population are the differences so considerable, on the 
one hand, between the interior plains of Louisiana, Missis- 
sippi, Alabama, and other Gulf Coast States, and their shores 
on tlie other, that we should explain thereby the almost 
uniform exemption of the former from infection ; although it 
should not be forgotten that differences may exist of a kind 
that have hitherto entirely escaped our attention. There is 
but owe fact always presenting itself wherever we turn our 
eyes, both within the yellow-fever zone and outside of it, 
and tliat is the close connexion of the disease witli sea coasts 
and the shores of navigable rivers. It is here that wo meet 
with tlie factor which appears to have direct control over tlie 
spread of the disease, viz. sea voyages, or maritime com- 
merce. Yelloiv fever goes practically no farther than the 
traffic hy sea; the disease for the most part finds its limit 


tvlicre that medium of communication ends. We are thus led 
to assume tliat the morbid poison clings to the ships thera- 
selveSj or to the goods^, chattels^ or persons which the ship 
carries, that it is taken up by ships from its indigenous or 
its epidemic foci, and transported to other places, where it gets 
the opportunity, under the conditions above mentioned, of 
putting forth its power. There are numerous well-authen- 
ticated observations proving beyond doubt that ships under 
those circumstances may become foci of infection, within 
which a crew made up of acclimatised persons may live 
without taking harm ; they do not make their injurious 
influence felt until susceptible individuals come on board in 
a distant port and enter the infected holds. In the same 
way a complete explanation appears to be furnished of the 
often observed fact that, where an infected ship is placed 
under strict quarantine, only those inhabitants of the port 
take the disease who have for one reason or another gone 
on board. If the rest of the population sickens, if new foci 
of infection are formed in the port, and the disease thereby 
becomes an epidemic on shore, then we must further assume 
that the morbid poison has been conveyed to land ; and this 
can only have taken place either by the wind blowing from 
the vessel shoreward s, or by personal intercourse, or by traffic 
in goods. 

§ 96. Alleged Diffusion by the Wind. 

That tJic ivind may he a carrier of the ycIlow-fcver poison 
cannot a, iiriori be denied ; and it may indeed be taken for 
granted that the diifusion of the disease to short distances 
does take place in that way. On the other hand, none of the 
observations claiming to prove a diffusion of the disease over 
wide tracts by currents of air are to be regarded as conclu- 
sive, inasmuch as, in all those cases, a conveyance of the 
morbific cause from place to place in other ways is not only not 
excluded, but is much the more likely thing to have occurred. 

CLisholm (I, p. 311) estimates tlie distance to ■wliicli yellow-fever 
poison may be borne by the wind at about six to ten feet ; othei's put 
it at a quarter of a mile and even more. In Sti'obel's account of the 


epidemic of 1 839 at Charleston,^ there is a statement according to which 
the extension of the disease from one vessel to three others lying at a 
distance of a quarter to half a mile took place by the wind. Milier 
reiDorts a similar fact in the well-known incident of 1861, intheharhour 
of St. Nazaire : of the ships in the neighbourhood of the infected craft, 
those only were attacked by the sickness which lay to the leeward, 
while those that anchored to windward escaped. It has been observed 
on various occasions, as for example in 1848 at New York, according to 
Bodinier, and at Philadelphia in 1858, according to Jewell, that only 
those of the population were affected with the disease who lived close 
to where the infected ships were berthed, and these only in so far as 
they were exposed to winds blowing across the ships. According to 
the official account of the epidemic of 1 855 at Norfolk, the town was 
infected from the subui-b of Gosport by the wind ; Jaspard and Potter 
(p. 20) assure ns that in Baltimore one could always predict the march 
of the disease from the prevalent direction of the wind. All these data, 
and others like them, deserve little confidence, inasmuch as the obser- 
vations are not free from error. In the instances cited from New York 
and Philadeli^hia, the persons living upon the quarantine ground, 
where the later cases of sickness occurred exclusively, had communi- 
cated with the infected ships dii'ectly or indirectly. Whether any 
■communication had taken place among the ships in the anchorage at 
Charleston in 1839 is not mentioned; but Milier expressly denies it, at 
all events, for the ships in the harbour of St. Nazaire. The extension 
of the disease from Gosport to Norfolk is much more easily explained, 
according to Williman, by the free traffic between these places by 
means of a steam ferry. The account by Cummins * of the disease 
being carried by the wind from the shore to a ship of war lying in the 
port is an instance of the scanty criticism that has been brought to bear 
on the discussion of this question ; the crew were strictly forbidden to 
land at the infected port, only the officers being allowed to go on shore 
at pleasure ; and yet the disease broke out on board the ship, not among 
the officers but among the crew. But nothing is said of the sailors who 
rowed the officers ashore and waited to row them back. 

In deciding on this question, wc have to remember, firstly, 
that any such conv^cyance of the yellow-fever poison by the 
wind from ships to the shore or to other ships, or conversely 
from the shore to ships, is, at all events extremely rare, if 
it occur at all ; secondly, that the very narrow limits of the 
foci of infection ^ indicate a high degree of tenacity or a 
considerable specific gravity of the poison ; and thirdly, that 

' 'Essay,' &c., p. 23. 
^ 'Lancet,' 1853, July. 

2 Heinemann has called attention to this fact in his experiences at Vera Cruz 
and neighbourhood. 


many observers have known tlio disease to spread regardless of 
tlio direction of the wind and even against the wind. No real 
importance, tliereforo, can bo attached to the wind as a 
carrier of the disease to any considerable distance. 

§ 97. Diffused by Personal Intercourse or Goods Traffic, 

There remain, then, only tJie intercourse of individuals, 
or the traffic in goods, as efficient means for the diffusion of 
the disease ; and, as a matter of fact, the history of yellow 
fever has at all times afforded, as we have seen, the most 
incontestable proofs that persons or effects, coming from a 
focus of infection, not unfrequently bring with them that 
which gives rise, under certain circumstances, to the forma- 
tion of a new centre of sickness ; while the multiplication of 
such centres of infection amounts to an epidemic. At the 
outset of this inquiry into the ways in which the disease 
spi'eads, I touched on the facts that tell against a diffusion 
by contagion proper, or against a reproduction of the morbid 
poison in the bodies of tho sick. I liold it to be beyond 
question, accordingly, that the yellow-fever patient is a 
medium of spreading the disease only in so far as the 
morbid poisons clings to him as it does to other objects ; 
that, in this respect, he plays no other part than his effects, 
or the coffers in which he keeps them, or than ships utensils, 
bales of goods, ballast, and in short, all that a ship carries, 
including perhaps the ship's hull itself. I hold also that 
the same applies to the formation of disease-foci on shore -^ 

* There are numerous accounts of the disease having been spread by infected 
linen, luggage, and other personal belongings : as, for example, those of Pariset 
et Mazet (pp. 89, 91) for the Cadiz epidemic of 1819; of Bally, and of Fran9ois 
et Pariset (p. 82), for the 182 1 epidemic in Catalonia; the official report of the 
epidemic of 1819 at New York ('Amer. Med. Kecorder,' iii, p. 203); that of 
Palloni (p. 36) for Leghorn ; of Harris (' lleport of the Physician-in-chief of the 
Marine Hospital at Quarantine,' Albany, 1857) for New York in 1856; of the 
Portugiiesc physicians (' Pelatorio,' &c., Lisboa, 1859) for the Lisbon epidemic of 
1857; of Ilochester, Thomas, Vance, and others, for the epidemic of 1878 in the 
United States. As to the morbid poison clinging to rooms, the following 
interesting fact comes from Port's Island, Permuda, under date 1869 ('Lancet,' 
1869, Oct., p. 583): — Tlic naval authorities had told oil' a number of sailors to 
clean out the quarantine, and tho work bad just been begun, when a 


that the potency and renewal of the morbid poison is 
dependent on certain influences without (the temperature 
a,nd the amount of moisture), and that it would seem to be 
essentially connected also with the processes of decomposi- 
tion in organic matters. At the same time, the limit to the 
diffusion of the disease hy way of the land traffic is soon 
reached. Notwithstanding the most careful scrutiny of all 
the factors herein concerned, I have been unable to discover 
any reason for this peculiar limitation, which is without 
analogy in the history of other acute infective diseases. We 
are confronted here with one of those riddles, of which the 
history of the acute infective disorders furnishes so many, 
and of which there will probably be no explanation until we 
succeed in becoming better acquainted with the nature of 
the morbid poisons themselves. 

§ 98. Endemic at Three Points Only. 

It has been abundantly shown in the course of these 
inquiries that the native habitat of yellow fever is not so 
extensive as the area of its diffusion. These inquiries should 
have enabled us to define the endemic foci of yellow fever 
somewhat precisely ; we may take them to be those places 
where the disease occurs habitually in sporadic cases, and 
where an epidemic may spring up from such sporadic cases 
and independently of any imported sickness. 

From that critical standpoint, then, we find, throughout 
the whole of the yellow-fever region, only tliree situations at 
which the disease bears ^n undoubtedly endemic character 
— the West Indies, the Mexican Gulf Coast, and part of the 
Guinea Coast. The headquarters of the disease are unques- 
tionably the West Indies, more particularly the Greater 

ship arrived from tbe West Indies with yellow fever on hoard. As the sick from 
this vessel had to be taken into the hospital, the cleaning was put off for a time, 
and tbe sailors ordered hack. Twenty-seven days after the last convalescent had 
left the hospital to go on hoard, and the vessel had sailed again for Halifax, the 
sailors, eight in number, resumed tbe work of cleaning, and within the next eight 
days two of them sickened and died ; a third fell ill six days later ; and the 
remaining five men were thereupon sent to Halifax on board a sloop-of-vvar, 
under tbe charge of a surgeon, who himself took tbe fever and died. 


AntilleSjM'rom which came the first relia1)le accounts of yellow- 
fever sickness among the European emigrants to the Western 
Hemisphere. Heinemann thinks himself justified in con- 
cluding from his inquiries " that the disease is endemic at 
only five places on the Mexican part of the Gulf Coast, viz. 
at Vera Cruz, Alvarado, Tlacotalpam, Laguna, and Campeche ; 
but even in these, ho adds, it is not endemic as an original 
malady, but as one naturalised after repeated importations 
from Cuba. Finally, on the Gtiinea Coast, the endemic focus of 
the disease appears to be exclusively Sierra Leone. Against 
the notion started, with no reason at all, by Pym and others, 
that this was the proper home of yellow fever,'^ and that the 
disease had been imported thence to the West Indies, it may 
be urged that the first accounts of yellow fever on the West 
Coast of Africa do not date back beyond the eighteenth 
century, and that it is much more probable, therefore, that 
this region was infected from the Antilles, afterwards becom- 
ing an endemic focus when the disease bad got natui-alised. 
Whether that endemic focus of disease includes other 
regions of the Guinea Coast as well, is at least very ques- 
tionable ; the disease has always been an importation on the 
Congo Coast, the coast of Scnegambia, the West African 
Islands, and, in fact, at all other places in that part of the 
world which have been visited by yellow fever at all. The 
same is true of the few regions of Eui-ope that have been 
attacked by it ; and it is further true, as we have already 
seen, for the continent of North America, and most pro- 
bably also for that of South America, particularly for Guiana, 
Venezuela and Peru. Finally, as to the position of the 

' It is difficult to decide wliether endemic foci of yellow fever occur iu certain 
of the Lesser Antilles, owing to the close intercourse that they all keep up with 
one another. The endemicity of the fever is denied for Martinique and Guade- 
loupe hy Leblond (p. 133), Rufz (II), Dutroulau (' Traite,' &c., pp. 34, 362), and 
St. Vel; for Barbadoes by Jackson (' Boston Med. and Surg. Journ./ 1867, July, 
p. 447); for Antigua by Furlong and Nicholson; for Grenada by Chisholm (I, 
p. 96); for Trinidad by Leblond (p. 136); and for Nassau (Bahamas) by the 
military reports (' Brit. Army Report' for 1864, vi, p. 255). On the other hand, 
we are entitled to consider St. Thomas, Santa Cruz, Santa Lucia, and St. Vincent 
as endemic seats of yellow fever, on the authority of Leblond, Gartner, Miller 
(III), and others. 

^ (11), p. 140. 

' Hence the equivalent " Bulam fever " for yellow fever. 


disease in Brazil, a decided opinion cannot be given off hand. 
It appears that yellow fever, since it first appeared in that 
country in 1 849 and 1 850, has never died out ; but whether 
that persistence for thirty years depends upon repeated 
importations of the morbid poison or upon the formation of 
endemic foci, cannot be decided at present, as there has 
been no thorough-going iuquiry into the subject. 

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